Age-specific global epidemiology of hydrocephalus: Systematic review, metanalysis and global birth surveillance. PLoS One. 2018;13:e0204926. [PMID: 30273390 PMCID: PMC6166961 DOI: 10.1371/journal.pone.0204926]

Novel insights into non-coding RNAs and their role in hydrocephalus

A large body of evidence has highlighted the role of non-coding RNAs in neurodevelopment and neuroinflammation. This evidence has led to increasing speculation that non-coding RNAs may be involved in the pathophysiological mechanisms underlying hydrocephalus, one of the most common neurological conditions worldwide. In this review, we first outline the basic concepts and incidence of hydrocephalus along with the limitations of existing treatments for this condition. Then, we outline the definition, classification, and biological role of non-coding RNAs. Subsequently, we analyze the roles of non-coding RNAs in the formation of hydrocephalus in detail. Specifically, we have focused on the potential significance of non-coding RNAs in the pathophysiology of hydrocephalus, including glymphatic pathways, neuroinflammatory processes, and neurological dysplasia, on the basis of the existing evidence. Lastly, we review the potential of non-coding RNAs as biomarkers of hydrocephalus and for the creation of innovative treatments.

Comprehensive Morphometric Analysis to Identify Key Neuroimaging Biomarkers for the Diagnosis of Adult Hydrocephalus Using Artificial Intelligence

BACKGROUND AND OBJECTIVES

Hydrocephalus involves abnormal cerebrospinal fluid accumulation in brain ventricles. Early and accurate diagnosis is crucial for timely intervention and preventing progressive neurological deterioration. The aim of this study was to identify key neuroimaging biomarkers for the diagnosis of hydrocephalus using artificial intelligence to develop practical and accurate diagnostic tools for neurosurgeons.

METHODS

Fifteen 1-dimensional (1-D) neuroimaging parameters and ventricular volume of adult patients with non-normal pressure hydrocephalus and healthy subjects were measured using manual image processing, and 10 morphometric indices were also calculated. The data set was analyzed using 8 machine, ensemble, and deep learning classifiers to predict hydrocephalus. SHapley Additive exPlanations (SHAP) feature importance analysis identified key neuroimaging diagnostic biomarkers.

RESULTS

Gradient Boosting achieved the highest performance, with an accuracy of 0.94 and an area under the curve of 0.97. SHAP analysis identified ventricular volume as the most important parameter. Given the challenges of measuring volume for clinicians, we identified key 1-D morphometric biomarkers that are easily measurable yet provide similar classifier performance. The results showed that the frontal-temporal horn ratio, modified Evan index, modified cella media index, sagittal maximum lateral ventricle height, and coronal posterior callosal angle are key 1-D diagnostic biomarkers. Notably, higher modified Evan index, modified cella media index, and sagittal maximum lateral ventricle height, and lower frontal-temporal horn ratio and coronal posterior callosal angle values were associated with hydrocephalus prediction. The results also elucidated the relationships between these key 1-D morphometric parameters and ventricular volume, providing potential diagnostic insights.

CONCLUSION

This study highlights the importance of a multifaceted diagnostic approach incorporating 5 easily measurable 1-D neuroimaging biomarkers for neurosurgeons to differentiate non-normal pressure hydrocephalus from healthy subjects. Incorporating our artificial intelligence model, interpreted through SHAP analysis, into routine clinical workflows may transform the diagnostic landscape for hydrocephalus by standardizing diagnosis and overcoming the limitations of visual evaluations, particularly in early stages and challenging cases.

Systematic follow-ups were not associated with reduced acute ventriculoperitoneal shunt dysfunction in infancy

AIM

Hydrocephalus surgery with a ventriculoperitoneal shunt is a life-saving treatment, but it has been associated with a high risk of dysfunction and complications. We investigated whether infants who received a ventriculoperitoneal shunt below 12 months of age had a reduced risk of acute shunt dysfunction if they were included in a structured follow-up programme.

METHODS

A population-based, retrospective chart review was performed at Uppsala University Children's Hospital, Sweden. Patients were identified by International Classification of Diseases, Tenth Revision codes and surgical codes from 1 January 2005 to 31 December 2019. Those who received the structured follow-up programme from April 2012 were compared with historical controls.

RESULTS

We identified 95 patients (66% male): 47 in the follow-up group and 48 controls. Their mean age was 2.6 (range 0-12) months. There was a high 44% acute shunt dysfunction rate during the first year after primary surgery: 38% in the follow-up group and 50% in the control group (p = 0.25). The difference was not significant.

CONCLUSION

The structured follow-up programme was not associated with a significant reduction in acute shunt dysfunction. Predictive models could help to identify patients at risk for shunt dysfunction and complications and improve surveillance and follow-up programmes.

Robotic hydrocephalus surgery: A systematic review of the effectiveness in neurosurgical interventions

BACKGROUND

Hydrocephalus is an abnormal buildup of cerebrospinal fluid (CSF) deep within the brain, resulting in clinical symptoms, including disorientation, vision disturbances, headaches, cognitive and developmental impairment. Traditional non-navigated surgical treatment, with ventriculoperitoneal (VP) shunt and endoscopic third ventriculostomy (ETV), may lead to complications such as shunt obstruction and inaccurate catheter placement. Robotics-assisted (RA) surgery has potential to improve precision of procedures. The objective of this systematic review is to assess the clinical effectiveness, complications, and benefits of RA surgical interventions in the case of hydrocephalus.

METHODS

PRISMA-guided literature search was done in databases including PubMed, Web of Science, Cochrane Reviews, Scopus, and Embase. Inclusion criteria encompassed English language, original, peer-reviewed journal articles in robotic-assisted surgical interventions in hydrocephalus. Patient demographics, robotic systems used, and results were extracted.

RESULTS

In total, 12 of the articles discussed robotic-assisted interventions for hydrocephalus. The robotic systems used included ROSA, NaoTrac, Remebot, and more. The findings established that the robotic systems are accurate. Almost all the studies showed successful outcomes with minimum robot-related complications like minor bleeding or conversion to manual surgery.

CONCLUSIONS

The evidence supporting the use of robot-assisted surgery for hydrocephalus management remains very limited in the literature. There is currently insufficient evidence to suggest that it offers any significant additional benefits in terms of patient outcomes, safety, or cost-effectiveness compared to conventional neurosurgical methods. Moreover, given the high maintenance costs of robotic workstations and prolonged surgery times, well-designed prospective controlled trials are needed to evaluate robotic effectiveness, compared to navigation-based techniques.

Safety and Complications of Ventriculoatrial Shunting in Elderly Patients: A Single-Center Retrospective Study

OBJECTIVE

The incidence of cerebrospinal fluid shunting among older adults is increasing. Ventriculoatrial (VA) shunting is a common shunting method, but research on VA shunting for elderly patients is limited. This retrospective study aimed to investigate the complication rate of VA shunting in older patients.

METHODS

Patients aged ≥65 years who underwent VA shunting at Tsukazaki Hospital between January 2019 and September 2023 were included. Follow-up duration, type of valve system, opening pressure, and postoperative complications (including overdrainage, symptomatic intracerebral hemorrhage, perioperative seizure, shunt system revision, infection, cardiopulmonary complications, cranial nerve injury, and other complications) were assessed.

RESULTS

Among 115 included patients (55% female and 71% primary hydrocephalus), the mean age and follow-up duration were 78 years and 464 days, respectively. Overdrainage, infection, symptomatic intracranial hemorrhage, and revision occurred in 22%, 2.6%, 1.7%, and 0.9% of patients, respectively. No other complications were observed. Among overdrainage cases, 84% were asymptomatic, and all cases were cured by resetting the opening pressure. Overdrainage was significantly higher among males (odds ratio [OR]: 3.34; 95% confidence interval [CI]: 1.30-8.56; P = 0.0097) and those aged <70 years (OR: 5.38; 95% CI: 1.32-21.84; P = 0.0226), while higher initial opening pressure (≥18 cmH2O) significantly reduced overdrainage (OR: 0.29; 95% CI: 0.11-0.79; P = 0.0123). All infections were treated using antibiotics, and 1 revision was due to failure of distal catheter implantation.

CONCLUSIONS

The observed complication rate of VA shunting in elderly patients was no higher compared with that of other age groups or other cerebrospinal fluid shunting techniques, reported in previous studies.

Hydrocephalus Pathophysiology and Epidemiology

Adult hydrocephalus is a common neurologic condition with an estimated prevalence of 85 per 100,000 globally, caused by abnormal cerebrospinal fluid (CSF) accumulation within the cerebral ventricles. Subtypes include idiopathic normal pressure hydrocephalus, posthemorrhagic, postinfectious, posttraumatic, and tumor-associated forms. Its pathophysiology involves glymphatic dysfunction, neuroinflammation, vascular compromise, and impaired CSF absorption. Despite advances in treatment, significant gaps remain in understanding its epidemiology, particularly in regards to regional variability and comorbidities, alongside unresolved questions about glymphatic pathways and neurodegenerative overlap. Standardized diagnostic and therapeutic frameworks are urgently needed.

Emergency Cranial Neurosurgery: An Audit of Operative Burden in a Specialized Neurosurgical Center in a Resource-Limited Setting

Background Neurosurgical emergencies pose significant challenges not only to healthcare systems but also to society and the economy. This audit examines the burden of emergency cranial neurosurgery procedures at a specialized center, highlighting the volume of cases and underscoring the need for additional dedicated neurosurgical facilities to meet the growing demand. Objective To assess the burden of emergency cranial neurosurgery procedures at the Punjab Institute of Neurosciences (PINS) in Lahore, Pakistan. Methodology This retrospective observational audit was conducted at the PINS, Lahore, analyzing data from patients who underwent emergency cranial neurosurgery over six months. A consecutive sampling technique was used, including all eligible patients while excluding those with incomplete records or non-cranial procedures. Data were collected from various hospital records and cross-verified for accuracy. Patients who underwent multiple procedures in a single surgery were recorded as a single entry. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 27.0 (Released 2020; IBM Corp., Armonk, NY, USA). Results A total of 562 patients, aged 7-90 years, with a mean age of 38.18 ± 18.42 years, underwent emergency cranial neurosurgery. Males accounted for 415 cases (73.84%), resulting in a female-to-male ratio of approximately 1:2.82. Traumatic cases comprised 241 patients (42.88%), with extradural hematoma diagnosed in 110 patients (34.27% of traumatic cases; 19.57% of total cases), acute subdural hematoma in 94 patients (29.28% of traumatic cases; 16.73% of total cases), and hemorrhagic contusion in 34 patients (10.59% of traumatic cases; 6.05% of total cases). Nontraumatic cases accounted for 321 patients (57.12%), with non-tumor hydrocephalus observed in 70 patients (29.05% of nontraumatic cases; 12.46% of total cases), intracerebral hematoma in 37 patients (15.35% of nontraumatic cases; 6.58% of total cases), and shunt malfunction in 23 patients (9.54% of nontraumatic cases; 4.09% of total cases). The most common surgical interventions performed were craniotomy for extradural hematoma in 106 patients (18.86%), ventriculoperitoneal shunt placement in 79 patients (14.06%), and tracheostomy in 54 patients (9.61%). Conclusions This audit highlights trauma and hydrocephalus as the leading causes of emergency cranial neurosurgical procedures. In developing countries like Pakistan, specialized neurosurgical centers, particularly their emergency departments and operating theaters, face a substantial patient load, emphasizing the urgent need for expanded facilities and resources.

Assessing Safety and Timing of Ventriculoperitoneal Shunt and Gastrostomy Tube Placement in Newborns

BACKGROUND

Ventriculoperitoneal Shunt placement (VPS) is a common surgical procedure for treating newborns with hydrocephalus. Due to poor feeding, these patients often require a gastrostomy tube (GT). There is controversy regarding safety and outcomes when patients require a VPS and GT.

METHODS

The Nationwide Readmission Database (NRD) was queried from 2016 to 2020 for newborns who underwent VPS placement during newborn hospitalization. Patient characteristics and outcomes were compared between those also requiring GT placement to those undergoing VPS alone. The timing of surgeries was also investigated.

RESULTS

4012 patients met inclusion criteria: 597 patients with VPS + GT placement and 3415 received only a VPS. Those undergoing VPS + GT had an increased proportion of shunt infection (3.2 % vs. 1.1 %) and mechanical complications (5.4 % vs. 0.7 %), often necessitating early removal (17 % vs. 12 %), all p < 0.05. The readmission rate was higher in those with VPS + GT, as were overall shunt complications upon readmission (11 % vs. 8 %, p = 0026). Regarding the timing of VPS and GT, those undergoing GT before VPS had higher rates of shunt and wound complications in newborn hospitalization, as well as shunt and GT complications upon readmission.

CONCLUSION

In this nationwide retrospective cohort analysis, placement of gastrostomy tubes during the same hospitalization as ventriculoperitoneal shunts increased shunt complications. In addition, the timing of shunt placement was found to be more favorable before gastrostomy placement. These findings should be considered for patients requiring both procedures.

TYPE OF STUDY

Retrospective cohort.

LEVEL OF EVIDENCE

Level III.

Adult Hydrocephalus Clinical Subtypes

Adult hydrocephalus comprises 4 pragmatic categories: (1) transition; (2) unrecognized congenital; (3) acquired; and (4) suspected idiopathic normal pressure hydrocephalus. Each of these groups has unique clinical presentations and care needs that require the involvement of adult neurosurgeons for diagnosis and treatment. Patients in all 4 of these categories benefit from longitudinal care for monitoring of their symptoms or assessing response to treatment.

Research priorities for non-invasive therapies to improve hydrocephalus outcomes

The Hydrocephalus Association organized two workshops with the support of the Rudi Schulte Research Institute and Cincinnati Children's Hospital Medical Center entitled "Developing Non-Invasive Hydrocephalus Therapies: Molecular and Cellular Targets", held September 27-29, 2023, in Dallas, TX, and "Developing Non-Invasive Hydrocephalus Therapies: Advancing Towards Clinical Trials", held April 12-13, 2024, in Cincinnati, OH. The goal of these workshops was to explore the frontiers of ongoing research for non-invasive therapies for the treatment of hydrocephalus across all etiologies and to improve patient outcomes at all stages of diagnosis and management. During the consensus-building discussions throughout the research workshops, basic, translational, and clinical scientists aimed to identify the next steps to develop novel treatments for hydrocephalus. This detailed report discusses the research priorities that emerged from these workshops to inspire researchers and guide studies towards better treatment for people living with hydrocephalus.

Neuroinflammatory pathways and potential therapeutic targets in neonatal post-hemorrhagic hydrocephalus

BACKGROUND

Post-hemorrhagic hydrocephalus (PHH) is a severe complication in premature infants following intraventricular hemorrhage (IVH). It is characterized by abnormal cerebrospinal fluid (CSF) accumulation, disrupted CSF dynamics, and elevated intracranial pressure (ICP), leading to significant neurological impairments.

OBJECTIVE

This review provides an overview of recent molecular insights into the pathophysiology of PHH and evaluates emerging therapeutic approaches aimed at addressing its underlying mechanisms.

METHODS

Recent studies were reviewed, focusing on molecular and cellular mechanisms implicated in PHH, including neuroinflammatory pathways, immune mediators, and regulatory genes. The potential of advanced technologies such as whole genome/exome sequencing, proteomics, epigenetics, and single-cell transcriptomics to identify key molecular targets was also analyzed.

RESULTS

PHH has been strongly linked to neuroinflammatory processes triggered by the degradation of blood byproducts. These processes involve cytokines, chemokines, the complement system, and other immune mediators, as well as regulatory genes and epigenetic mechanisms. Current treatments, primarily surgical CSF diversion, do not address the underlying molecular pathology. Emerging therapies, such as mesenchymal stem cell-based interventions, show promise in modulating immune responses and mitigating neurological damage. However, concerns about the safety of these novel approaches in neonatal populations and their potential effects on brain development remain unresolved.

CONCLUSIONS

Advanced molecular tools and emerging therapies have the potential to transform the treatment of PHH by targeting its underlying pathophysiology. Further research is needed to validate these approaches, enhance their safety profiles, and improve outcomes for infants with PHH.

IMPACT STATEMENT

1. This review elucidates the molecular complexities of post-hemorrhagic hydrocephalus (PHH) by examining specific immune pathways and their impact on disease pathogenesis and progression. 2. It outlines the application of genomic, epigenomic, and proteomic technologies to identify critical molecular targets in PHH, setting the stage for innovative, targeted therapeutic approaches that could improve the outcomes of neonates affected by PHH. 3. It discusses the potential of gene and stem cell therapies in treating PHH, offering non-surgical alternatives and focusing on the underlying neuroinflammatory mechanisms.

Impact of Surgical Timing on Ventriculoperitoneal Shunt Failure Rates: A Population-Based Cohort Study

OBJECTIVE

Hydrocephalus is a common neurosurgical condition treated primarily through ventriculoperitoneal (VP) shunt placement. This study aims to investigate the relationship between the timing of VP shunt surgery (on-call vs. regular hours) and shunt failure rates.

METHODS

In this single-center, population-based observational cohort study, all adult patients who underwent VP shunt surgery were included. The main outcome was reoperation due to shunt failure within 12 months of the index surgery, comparing rates between procedures performed during regular hours and on-call periods. Adjustments for confounders were made using multivariable logistic regression.

RESULTS

Out of 810 cases included, 25% underwent surgery during on-call hours. Shunt failure occurred in 10% of cases, most often due to infection. Patients operated on during on-call hours had a significantly higher rate of shunt failure compared to those operated on during regular hours (17% vs. 7.9%, P < 0.001). However, after adjusting for confounders in a multivariable logistic regression, this relationship was no longer statistically significant (OR: 1.60, P = 0.073).

CONCLUSIONS

The rate of shunt failure was significantly greater in surgeries conducted during on-call hours as opposed to regular hours, but this was not statistically significant after adjusting for confounders. Therefore, the timing of VP shunt surgery may not be an independent risk factor for shunt failure. High-risk scenarios still deserve added caution, and further research is needed to identify factors influencing shunt outcomes and develop strategies to minimize failure rates.

Risk Factors for 30-Day Postoperative Infection in Pediatric Ventricular Shunts for Hydrocephalus

BACKGROUND

Ventricular shunt infections lead to significant morbidity and mortality. This study aimed to identify risk factors for 30-day postoperative infection outcomes of ventricular shunt surgery for pediatric hydrocephalus.

METHODS

This retrospective cohort study used the National Surgical Quality Improvement Program Pediatric database for the years 2016-2021. Patients were included in this study if they were <18 years old and underwent ventricular shunt surgery. The primary outcome was 30-day postoperative shunt infection. A multivariable logistic regression analysis was performed using 14 prognostic variables to determine factors associated with infection risk.

RESULTS

The study included 10,878 patients with a mean (SD) age of 3.1 (4.83) years; 44.2% were girls. The overall 30-day postoperative shunt infection rate was 3.7%. Infection risk increased in patients with nutritional support, longer operating room time, and congenital hydrocephalus. Conversely, infection risk decreased with increasing patient age, delivery of intraoperative intraventricular antibiotics, and first-time shunt placement. Variables that did not significantly affect the risk of 30-day postoperative shunt infection included sex, body mass index, ostomy, tracheostomy, neuromuscular disease, structural pulmonary/airway abnormality, steroid use within 30 days, antibiotic-impregnated shunt use, and endoscopy for catheter placement.

CONCLUSIONS

Various modifiable and nonmodifiable factors are associated with postoperative shunt infections. Recognizing and modifying risk factors can reduce pediatric shunt infections, thereby preventing revisions and improving therapeutic outcomes and quality of life.

Neurosurgical shunt treatment of pediatric hydrocephalus: epidemiology and influencing factors on revision surgeries: a single-center retrospective analysis of 131 patients

BACKGROUND

Pediatric hydrocephalus is a result of a dysfunction of cerebrospinal fluid circulation, and it has diverse pathogeneses. This study investigates the epidemiology of pediatric hydrocephalus, as well as the influences of primary etiology and implant type on treatment complications and the development of new therapeutic approaches and strategies.

METHODS

Between 2013 and 2018, a retrospective analysis of 131 children, who were suffering from hydrocephalus, was conducted. Medical charts, operative reports and clinical follow-up visits were reviewed. Statistical analysis was performed using t-test/ANOVA and Kruskal-Wallis Test/Mann-Whitney U Test.

RESULTS

The most common pathogeneses of hydrocephalus among our patients were meningomyelocele-associated and posthemorrhagic. The majority of patients received a programmable differential pressure valve (PPV, 77.8%) or a fixed differential pressure valve with a gravitational unit (FPgV, 14.8%). Among 333 shunt-associated surgeries, 66% of surgeries were revision surgeries and were performed because of mechanical shunt dysfunction (61%), infection (12%), or other reasons (27%). The median rate of revisions within one year for each patient was 0.15 (IQR25-75: 0.00-0.68) and was influenced by etiology (P=0.045) and valve type (P=0.029). The highest rates were seen in patients with posthemorrhagic hydrocephalus and in those with FPgVs; the lowest rates were seen in patients with meningomyelocele-associated hydrocephalus and PPVs. The occurrence of mechanical dysfunctions was correlated with FPgV patients (P=0.014). Furthermore, the median time interval between initial shunt surgery and onset of infection was shorter than that between initial surgery and mechanical dysfunction (P=0.033).

CONCLUSIONS

Based on this research, we can state several factors that influence revision surgeries in pediatric shunt patients. With the assessment of patients' risk profiles, physicians can classify pediatric shunt patients and thus avoid unnecessary examinations or invasive procedures. Furthermore, medical providers can prevent revision surgeries if they choose shunt material in accordance with a patient's associated shunt complications.

The impact of architectural modifications on relative resistance to fluid flow in ventricular catheters

Introduction

Although many ventricular catheter designs exist for hydrocephalus treatment, few standardized studies assess outflow resistance and the impact of design modifications on shunt drainage. This study represents the in-vitro assessment of various architectural modifications on catheter flow rate and pressure, focusing on bulk outflow dynamics and occlusion with whole blood-inoculated cerebrospinal fluid.

Methods

Catheters were manufactured utilizing a novel catheter production setup with 16 variations from standard catheters, including but not limited to changes in: hole number, hole dimensions, catheter lumen dimension, and catheter lumen impingement. These catheters were tested in a portable custom-made ventricular catheter testing device to analyze relative resistance to flow between catheter designs. A subset of catheters with varying lumen diameters was tested in 0.30 mL/min saline flow with 2.5% blood to simulate early blood exposure.

Results

With increasing hole and lumen diameter, we found a significant decrease in overall catheter relative resistance using DIH20 (P < 0.001 and P < 0.002 respectively, n = 5). With increasing lumen diameters, blood assays showed a significant increase in the time to complete obstruction (P = 0.027, n = 5). Lumen impingement, representing one obstruction-based pinch point in the lumen, showed a considerable increase in relative resistance as obstruction diameter increased and lumen diameter at the pinch point decreased (P = 0.001, n = 5). Removal of specific catheter hole rows trended toward an increase relative resistance after 75% of catheter holes were blocked, but the effect in relative outflow resistance is otherwise minimal (P > 0.05, n = 5) and no effect was observed with blocking segments.

Conclusion

This study implemented a novel method of rapid catheter manufacturing to systematically produce ventricular catheters with specific catheter architecture. By testing variables independently, we found that catheters with changes to the lumen diameter had the most dramatic shifts in overall relative resistance between catheter designs. Similarly, testing in the acute in-vitro blood assay demonstrated that smaller diameter catheters have a higher propensity to obstruct with blood compared to catheters with larger diameter. Relative resistance impacts fluid outflow efficiency, which may translate to clinical outcomes for hydrocephalus patients. These findings help us understand catheter architectural effects on resistance and inform future designs for specific ventricle morphologies.

Optimal trajectory of the neuroendoscope for third ventricle pavement access

Background and aim

Endoscopic Third Ventriculostomy (ETV) is used to treat hydrocephalus, an abnormal cerebrospinal fluid accumulation in brain ventricles. By defining a new trajectory and entry point interval, we aim to establish a standardized approach for FreeHand ETV, a vital technique when specialized tools are unavailable, or during emergencies.

Methods

187 MRIs were analyzed, with 30 having hydrocephalus. A pathway crossing the cranial bone, interventricular foramen (of Monro) and tuber cinereum was outlined. Measurements involved distances to cranial sutures, pathway angles and depths, and distances to important anatomical landmarks. Comparisons between hydrocephalic and non-hydrocephalic patients were made while assessing variations linked to age, sex and Evan's index.

Results

Significant differences were found, notably for depth (93.520 ± 7.228 mm), coronal plane angulation (10.982° ± 6.119°), distance to the sagittal suture (18.957 ± 8.608 mm), and distance to the superior frontal sulcus (7.00 mm). Other variables did not differ significantly between groups, including for the sagittal plane angulation (2.549° ± 3.576°) and the distances to the precentral sulcus (19.93 ± 7.955 mm), and to the coronal suture (10.55 mm).

Conclusion

The new approach, situated close to cranial sutures and distant to the precentral and superior frontal sulcus, shows promise in enhancing surgical precision and outcomes for hydrocephalus management.

Deep-Learning-based Automated Identification of Ventriculoperitoneal-Shunt Valve Models from Skull X-rays

INTRODUCTION

Ventriculoperitoneal shunts (VPS) are an essential part of the treatment of hydrocephalus, with numerous valve models available with different ways of indicating pressure levels. The model types often need to be identified on X‑rays to assess pressure levels using a matching template. Artificial intelligence (AI), in particular deep learning, is ideally suited to automate repetitive tasks such as identifying different VPS valve models. The aim of this work was to investigate whether AI, in particular deep learning, allows the identification of VPS models in cranial X‑rays.

METHODS

959 cranial X‑rays of patients with a VPS were included and reviewed for image quality and complete visualization of VPS valves. The images included four VPS model types: Codman Hakim (n = 774, 81%), Codman Certas Plus (n = 117, 12%), Sophysa Sophy Mini SM8 (n = 35, 4%) and proGAV 2.0 (n = 33, 3%). A Convolutional Neural Network (CNN) was trained using stratified five-fold cross-validation to classify the four VPS model types in the dataset. A finetuned CNN pretrained on the ImageNet dataset as well as a model trained from scratch were compared. The averaged performance and uncertainty metrics were evaluated across the cross-validation splits.

RESULTS

The fine-tuned model identified VPS valve models with a mean accuracy of 0.98 ± 0.01, macro-averaged F1 score of 0.93 ± 0.04, a recall of 0.94 ± 0.03 and a precision of 0.95 ± 0.08 across the five cross-validation splits.

CONCLUSION

Automatic classification of VPS valve models in skull X‑rays, using fully automatable preprocessing steps and a CNN, is feasible. This is an encouraging finding to further explore the possibility of automating VPS valve model identification and pressure level reading in skull X‑rays.

Incidence of Communicating Hydrocephalus Following Intraventricular Hemorrhage Among Adult Patients Treated at a Hospital in Jeddah, Saudi Arabia: A Retrospective Study

Introduction Intraventricular hemorrhage is a severe condition caused by bleeding within the brain ventricles. It is often due to trauma, tumors, vascular malformation, aneurysm, oxygen deprivation, or idiopathic. A common complication associated with intraventricular hemorrhage is hydrocephalus, which is the accumulation of cerebrospinal fluid in the ventricles. Hydrocephalus can be classified as communicating or non-communicating. This study aimed to evaluate the incidence of communicating hydrocephalus after intraventricular hemorrhage. Methods This retrospective study was conducted at King Abdulaziz University Hospital in Jeddah, Saudi Arabia, and included 52 adult patients treated between 2012-2022 who met the eligibility criteria. We examined the relationships among age, sex, length of hospitalization, presenting symptoms, co-morbidities, Evans index, Graeb score, Glasgow Coma Score, survival, and ventriculoperitoneal shunt complications through univariate and bivariate analyses. The Shapiro-Wilk test was used to evaluate data distribution. Differences between groups were analyzed using the chi-square test for categorical variables and the Mann-Whitney U test for non-parametric variables. Results The median age of the participants was 54 years, with a male predominance (57.7%). Motor dysfunction was the most frequently reported symptom at presentation (48.1%). Among the 30 patients who developed hydrocephalus after intraventricular hemorrhage, 70% had communicating hydrocephalus. There was a substantial correlation between mortality and hydrocephalus type (P =0.020). Conclusion Intraventricular bleeding is associated with an increased risk of communicating hydrocephalus, with an incidence rate of 3% per person-year.

Adult Internal Cerebrospinal Fluid Shunt Overall Survival: A Meta-Analysis of Restricted Mean Survival Times from Reconstructed Kaplan-Meier Data

OBJECTIVE

To assess the overall survival (OS) of internal cerebrospinal fluid shunt (ICSFS) in the adult population.

METHODS

MEDLINE database was searched from 2000 to 2023 to identify studies reporting on ICSFS OS. Only articles reporting on adult ICSFS OS by a Kaplan-Meier (KM) OS curve were included. Numerical data were extracted from KM curves and were then reconstructed to estimate 3, 6, 9, 12, 18, 24, 36, 48, and 60 months restricted mean survival times (RMSTs). RMSTs of ICSFS and its SE at each time of interest were used as summary measure and primary outcome across studies. To account for the effect of between-study heterogeneity, RMSTs were pooled using a random effects model.

RESULTS

Out of 421 screened studies, only 6 were included in the meta-analysis. Calculated ICSFS OS at 3, 6, 9, 12, 18, 24, 36, 48, and 60 months were 92.4% (95% CI, 89.6-95.2), 89.5% (95% CI, 86.3-92.8), 87.5% (95% CI, 83.9-91.1), 85.2% (95% CI, 80.4-90.0), 83.4% (95% CI, 79.0-87.9), 81.6% (95% CI, 76.7-86.5), 78.8% (95% CI, 72.9-84.6), 76.7% (95% CI, 70.3-83.1), and 74.5% (95% CI, 67.8-81.1), respectively. There was a significant heterogeneity as indicated by a high I2 value of 82.5% (95% CI, 63.1-91.7). Heterogeneity test of Q = 28.63 was also significant (P < 0.001).

CONCLUSIONS

On contrary to what one might think, there are few available studies assessing adult ICSFS OS. We used a novel technique to meta-analyze adult ICSFS OS. ICSFS failure rate is maximal within the 3 to 6 postoperative months. Afterward, the risk slowly decreases over time. At 5 years, less than three quarters of the patients still have a naïve functional ICSFS never revised.

A case report of mental disorder caused by shunt blockage after hydrocephalus surgery

Introduction

Hydrocephalus is a form of communication hydrocephalus syndrome characterized by ventricular enlargement and normal intraventricular pressure. The primary clinical manifestations include gait disturbances, cognitive dysfunction, urinary incontinence, and either elevated or normal intracranial pressure. This paper presents a case of a mental disorder resulting from inadequate drainage following a ventriculoperitoneal shunt procedure for hydrocephalus. The case report aims to enhance clinicians' understanding of such organic brain lesions, which are prone to misdiagnosis and inappropriate treatment, thereby improving differential diagnostic skills.

Case presentation

This case report describes a 34-year-old male with a 16-year history of depressive disorder, previously managed with 150 mg of venlafaxine daily, 7.5 mg of zopiclone every night, and 2.4 g of piracetam every day. The patient underwent a ventriculoperitoneal shunt procedure for hydrocephalus, leading to the development of a mental disorder attributable to poor drainage from the shunt tube. Initial symptoms consisted of low mood, decreased interest, and cognitive impairment. Despite psychiatric consultation and antidepressant treatment, there was no improvement in his condition. The final diagnosis was an organic mental disorder. Following an increase in shunt drainage and the administration of a low dose of olanzapine, the patient's psychiatric symptoms showed significant improvement.

Conclusion

Reporting this case seeks to enhance clinicians' awareness of the psychiatric manifestations of organic brain lesions, expand the differential diagnostic approach for psychiatrists, and improve diagnostic accuracy. Additionally, it emphasizes the need for cautious use of psychiatric medications, appropriate symptomatic management, and timely referral when necessary.

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.

Revision and Infection Rate in 728 Shunt-Treated Adult Hydrocephalus Patients-a Single-Center Retrospective Study

BACKGROUND

Hydrocephalus is a common diagnosis worldwide that is treated with shunts and is associated with potential life-threatening risks of shunt dysfunction and infection. We investigated differences in rates of shunt revisions and infections including various factors in patients with different causes of hydrocephalus. We also studied causes of infections and efficacy of perioperative antibiotic regimens. Our objective was to identify patients at risk of higher revision and infection rates after shunt treatment.

METHODS

We conducted a retrospective single-center cohort study including 728 adult patients who underwent shunt surgery between 2013 and 2019 at our center.

RESULTS

Overall revision rate was 20.1%, and infection rate was 4.8%. Infection was detected in 24% of all revisions. The main location for a positive culture was cerebrospinal fluid (67.5%), frequently caused by Cutibacterium acnes (60%). Younger age and prior shunts were the only predictors confirmed in multivariate Cox regression as significantly increasing the risk of revision surgery. Multivariate Cox regression analysis of infection risk factors showed that obstructive hydrocephalus, prior shunt, and cloxacillin significantly increased risk of shunt infection.

CONCLUSIONS

We found revision and infection rates in accordance with other studies. We showed a significantly increased risk in younger patients. Previous shunts also increased the risk of revisions and infections. We showed a small but significant effect of perioperative prophylaxis with broader-spectrum antibiotics compared with cloxacillin. Our study identified a group of younger patients with congenital hydrocephalus and prior implants with an increased risk of shunt infection in whom additional preventive measures should be employed.

Hydrocephalus: An update on latest progress in pathophysiological and therapeutic research

Hydrocephalus is a severe and life-threatening disease associated with the imbalance of CSF dynamics and affects millions globally at any age, including infants. One cause of pathology that is wide-ranging is genetic mutations to post-traumatic injury. The most effective current pharmacological treatments provide only symptomatic relief and do not address the underlying pathology. At the same time, surgical procedures such as VP shunts performed in lower-income countries are often poorly tolerated due to insufficient diagnostic resources and suboptimal outcomes partially attributable to inferior materials. These problems are compounded by an overall lack of funding that keeps high-quality medical devices out of reach for all but the most developed countries and even among those states. There is a massive variance in treatment effectiveness. This review indicates the necessity for innovative and low-cost, accessible treatment strategies to close these gaps, focusing on current advances in novel therapies, including Pharmacological, gene therapy, and nano-based technologies, which are currently at different stages of clinical trial phases. This review provides an overview of pathophysiology, current treatments, and promising new therapeutic strategies for hydrocephalus.

A Bidirectional Mendelian Randomization Study of the Causal Association Between Ischemic Stroke, Coronary Heart Disease, and Hydrocephalus

BACKGROUND

The association among coronary heart disease, ischemic stroke, and hydrocephalus remains ambiguous.

OBJECTIVES

There is a need for a Mendelian randomization study to evaluate the underlying causality between coronary heart disease, ischemic stroke, and hydrocephalus.

METHODS

The data source utilized genome-wide association studies, employing a threshold of p < 5 × 10-8 to identify single nucleotide polymorphisms strongly linked to ischemic stroke and coronary heart disease as instrumental variables (IVs). Five methods-inverse variance weighted (IVW), Mendelian randomization (MR) Egger, Weighted Median, Weighted mode, and Simple mode-utilized the selected IVs to estimate the causality between ischemic stroke, coronary heart disease, and hydrocephalus.

RESULTS

The IVW demonstrated that ischemic stroke and coronary heart disease serve as risk factors for hydrocephalus (odds ratio [OR] = 1.650, 95% CI: 1.066-2.554, p = 0.025; OR = 1.307, 95% CI: 1.023-1.668, p = 0.032). Both the MR-Egger intercept test and Cochran's Q test affirmed the relative reliability of the IVW analysis results. However, no evidence of a reverse causation was observed between hydrocephalus and coronary heart disease or ischemic stroke.

CONCLUSIONS

Coronary heart disease and Ischemic stroke may increase the risk of hydrocephalus.

Unilateral Exophthalmos as the First Sign of Chronic Obstructive Hydrocephalus in a Pediatric Patient: A Case Report

Orbital complications are rare manifestations of congenital hydrocephalus. We present a case of a child presenting with unilateral exophthalmos and palpebral edema as a result of a chronic increased intracranial pressure and severe enlargement of the ventricular system. The initial presentation in our 13-year-old male patient was progressive right eyelid swelling. Echo-sonography showed right eyelid edema while computed tomography revealed internal hydrocephalus and cerebral edema. In the later course, an enlarging right bulb protrusion occurred, which was repositioned immediately after placing a ventriculoperitoneal shunt. The right eyelid edema decreased in the week following the procedure. The postoperative status was confirmed by magnetic resonance imaging, which also showed a right orbital roof defect. The observed orbital roof defect was considered a cause of the eye bulb protrusion in this case and highlights the possibility of orbital signs as the first manifestations of non-traumatic obstructive hydrocephalus in children.

Insights on pathophysiology of hydrocephalus rats induced by kaolin injection

Hydrocephalus can affect brain function and motor ability. Current treatments mostly involve invasive surgeries, with a high risk of postoperative infections and failure. A successful animal model plays a significant role in developing new treatments for hydrocephalus. Hydrocephalus was induced in Sprague-Dawley rats by injecting 25% kaolin into the subarachnoid space at the cerebral convexities with different volumes of 30, 60 and 90 μL. Magnetic resonance imaging (MRI) was performed 1 month and 4 months after kaolin injection. The behavioral performance was assessed weekly, lasting for 7 weeks. The histopathological analyses were conducted to the lateral ventricles by hematoxylin-eosin (HE) staining. Transcriptomic analysis was used between Normal Pressure Hydrocephalus (NPH) patients and hydrocephalus rats. MRI showed a progressive enlargement of ventricles in hydrocephalus group. Kaolin-60 μL and kaolin-90 μL groups showed larger ventricular size, higher anxiety level, bigger decline in body weight, motor ability and cognitive competence. These symptoms may be due to higher-grade inflammatory infiltrate and the damage of the structure of ependymal layer of the ventricles, indicated by HE staining. The overlap upregulated genes and pathways mainly involve immunity and inflammation. Transcriptomic revealed shared pathogenic genes CD40, CD44, CXCL10, and ICAM1 playing a dominance role. 60 μL injection might be recommended for the establishment of hydrocephalus animal model, with a high successful rate and high stability. The hydrocephalus model was able to resemble the inflammatory mechanism and behavioral performance observed in human NPH patients, providing insights for identifying therapeutic targets for hydrocephalus.

Are ventriculopleural shunts the second option for treating hydrocephalus? A meta-analysis of 543 patients

BACKGROUND

Some centers utilize ventriculopleural shunt (VPLS) for treating hydrocephalus when conventional approaches are not feasible. Nonetheless, the literature regarding this approach is scarce.

PURPOSE

Evaluate the outcomes of VPLS through a single-arm meta-analysis.

METHODS

Following PRISMA guidelines, the authors systematically searched for articles utilizing the VPLS in a cohort with more than four patients. Outcomes included: mortality, pleural effusion, number of patients who underwent revisions, obstructions, shunt migration, emphysema, and subdural hematoma.

RESULTS

A total of 404 articles were reviewed, resulting in the inclusion of 13 retrospective studies encompassing 543 patients, with the majority being children (62.6 %). The median average follow-up period was 35.4 months (10-64.1). After analysis, results yielded a revision rate of 54 % (95 % CI: 44 %-64 %; I2=73 %). The most common complication observed was pleural effusion, with a post-analysis incidence of 16 % (95 % CI: 11 %-21 %; I2=63 %), followed by infections at 7 % (95 % CI: 4 %-10 %; I2=33 %). Shunt obstruction occurred in 13 % (95 % CI: 4 %-21 %; I2=84 %) of cases after analysis, while migrations, overdrainage, subdural hematoma, and cutaneous emphysema had minimal occurrence rates (0 %, 95 % CI: 0 %-1 %; I2=0 %). Notably, there were no reported cases of shunt-related mortality.

CONCLUSION

VPLS can be considered when there are no other suitable options for placing the distal catheter. However, the notable rates of shunt revisions, pleural effusion, infections, and the inherent heterogeneity of outcomes currently limit the widespread adoption of VPLS. In this scenario, other alternatives should be given priority.

North American Fetal Therapy Network: Maternal Outcomes in Fetal Aqueductal Stenosis

INTRODUCTION

Fetal aqueductal stenosis (AS) affects approximately 1:1,000 pregnancies. Obstruction of cerebral spinal fluid circulation occurs at the aqueduct of Sylvius, leading to progressive hydrocephalus and macrocephaly, which often necessitates cesarean section (CS). The purpose of this study was to describe maternal outcomes associated with fetal AS.

METHODS

This study is conducted through the North American Fetal Therapy Network (NAFTNet). Subjects with a prenatal diagnosis of severe fetal central nervous system ventriculomegaly were recruited and followed longitudinally. Maternal events around the delivery of fetuses with AS were recorded and analyzed.

RESULTS

Thirty-seven subjects with fetal AS confirmed by neonatal neuroimaging were analyzed. The average gestational age at delivery was 36.7 weeks. Overall, 86% were delivered by CS, and 62% of these were elective. Ninety-one percent of CSs were performed through a Pfannenstiel abdominal incision. A classical uterine incision was required in 13% of cesarean deliveries. The peripartum complication rate was 27%.

CONCLUSION

Women carrying a fetus with AS were at risk for preterm birth, cesarean delivery, a classical uterine incision, and peripartum complications. These data highlight the maternal morbidity associated with fetal AS and the potential benefit of in utero therapy not only for neonatal outcomes but also for maternal outcomes.

Impact of aquaporin-4 and CD11c + microglia in the development of ependymal cells in the aqueduct: inferences to hydrocephalus

AQP4 is expressed in the endfeet membranes of subpial and perivascular astrocytes and in the ependymal cells that line the ventricular system. The sporadic appearance of obstructive congenital hydrocephalus (OCHC) has been observed in the offspring of AQP4-/- mice (KO) due to stenosis of Silvio's aqueduct. Here, we explore whether the lack of AQP4 expression leads to abnormal development of ependymal cells in the aqueduct of mice. We compared periaqueductal samples from wild-type and KO mice. The microarray-based transcriptome analysis reflected a large number of genes with differential expression (809). Gene sets (GS) associated with ependymal development, ciliary function and the immune system were specially modified qPCR confirmed reduced expression in the KO mice genes: (i) coding for transcription factors for ependymal differentiation (Rfx4 and FoxJ1), (ii) involved in the constitution of the central apparatus of the axoneme (Spag16 and Hydin), (iii) associated with ciliary assembly (Cfap43, Cfap69 and Ccdc170), and (iv) involved in intercellular junction complexes of the ependyma (Cdhr4). By contrast, genes such as Spp1, Gpnmb, Itgax, and Cd68, associated with a Cd11c-positive microglial population, were overexpressed in the KO mice. Electron microscopy and Immunofluorescence of vimentin and γ-tubulin revealed a disorganized ependyma in the KO mice, with changes in the intercellular complex union, unevenly orientated cilia, and variations in the planar cell polarity of the apical membrane. These structural alterations translate into reduced cilia beat frequency, which might alter cerebrospinal fluid movement. The presence of CD11c + microglia cells in the periaqueductal zone of mice during the first postnatal week is a novel finding. In AQP4-/- mice, these cells remain present around the aqueduct for an extended period, showing peak expression at P11. We propose that these cells play an important role in the normal development of the ependyma and that their overexpression in KO mice is crucial to reduce ependyma abnormalities that could otherwise contribute to the development of obstructive hydrocephalus.

Flexible low-profile external ventricular drain catheter for real-time brain monitoring

External ventricular drainage is one of the most common neurosurgical procedures in the world for acute hydrocephalus, which must be performed carefully by a neurosurgeon. Although various neuromonitoring external ventricular drain (EVD) catheters have been utilized, they still suffer from rigidity and bulkiness to mitigate post-EVD placement trauma. Here, we introduce a flexible and low-profile smart EVD catheter using a class of technologies with sensitive electrical materials, seamless integration, and flexible mechanics, which serves as a highly soft and minimally invasive device to monitor electrical brain signals. This device reliably captures biopotentials in real time while exhibiting remarkable flexibility and reliability. The seamless integration of its sensory system promises a minimally invasive EVD placement on brain tissue. This work validates the device's distinct characteristics and performances through in vitro experiments and computational analysis. Collectively, this device's exceptional patient- and user-friendly attributes highlight its potential as one of the most practical EVD catheters.

Ventricular catheter tissue obstruction and shunt malfunction in 9 hydrocephalus etiologies

OBJECTIVE

Hydrocephalus is a neurological disorder with an incidence of 80-125 per 100,000 births in the United States. The most common treatment, ventricular shunting, has a failure rate of up to 85% within 10 years of placement. The authors aimed to analyze the association between ventricular catheter (VC) tissue obstructions and shunt malfunction for each hydrocephalus etiology.

METHODS

Patient information was collected from 5 hospitals and entered into a REDCap (Research Electronic Data Capture) database by hydrocephalus etiology. The hardware samples were fixed, and each VC tip drainage hole was classified by tissue obstruction after macroscopic analysis. Shunt malfunction data, including shunt revision rate, time to failure, and age at surgery, were correlated with the degree of tissue obstruction in VCs for each etiology.

RESULTS

Posthemorrhagic hydrocephalus was the most common etiology (48.9% of total cases). Proximal catheter obstruction was the most frequent cause of hardware removal (90.4%). Myelomeningocele (44% ± 29%), other congenital etiologies (48% ± 40%), hydrocephalus with brain tumors (45% ± 35%), and posthemorrhagic hydrocephalus (41% ± 35%) showed tissue aggregates in more than 40% of the VC holes. A total of 76.8% of samples removed because of symptoms of obstruction showed cellular or tissue aggregates. No conclusive etiological associations were detected when correlating the percentage of holes with tissue for each VC and age at surgery, shunt revision rates, or time between shunt implantation and removal.

CONCLUSIONS

The proximal VC obstruction was accompanied by tissue aggregates in 76.8% of cases. However, the presence of tissue in the VC did not seem to be associated with hydrocephalus etiology.

Trends in the Treatment of Pediatric Hydrocephalus Since 2014: Understanding the Role of the 2014 Hydrocephalus Guidelines

BACKGROUND AND OBJECTIVES

The management of hydrocephalus has significantly changed over the past decade. Endoscopic third ventriculostomy has become more prevalent, and shunt surgery has become more protocolized through research efforts by the Hydrocephalus Clinical Research Network. In 2014, the Pediatric Hydrocephalus Guidelines were first published, providing a cohesive source for clinical guidance. We planned to investigate national trends in the management of pediatric hydrocephalus after the publication of the 2014 Pediatric Hydrocephalus Guidelines as guidelines act as a compilation of historic and recent literature in a scientific field.

METHODS

A multipronged approach was used to evaluate changes in the treatment of pediatric hydrocephalus since 2014. First, we queried the Pediatric Health Information System between 2013 and 2018 to identify national trends in shunt procedures for hydrocephalus. To assess the recommendation in the guidelines to use antibiotic-impregnated catheters (AICs) in shunts, national sales records of AICs were obtained from 2 large neurosurgical device companies.

RESULTS

A total of 11,179 shunt procedures were performed within the Pediatric Health Information System database in the study period. In the preguideline publication period (2013-2014), there was a shunt revision-to-placement ratio of 1.63 while in the postguideline publication period (2015-2018), there was a ratio of 0.84 (P < .0001). National sales data revealed that antibiotic-impregnated drain sales increased from 2% to 77% since publication.

CONCLUSION

Findings from this investigation suggest progress in pediatric hydrocephalus management since 2014. The shunt revision-to-placement ratio improved, and the use of AICs increased over this period. Improved outcomes are likely associative findings rather than causative with the guidelines representing a culmination of widespread changes in hydrocephalus care such as increased use of endoscopic third ventriculostomies, protocolized care, and image-guided shunt placement. Further research into the impact of clinical practice guidelines is needed to better understand the impact of this tool on surgeons and patient care.

Falciform technique in laparoscopic revision of distal catheter obstruction: an evaluation

Background

Ventriculoperitoneal (VP) shunting is a cornerstone treatment for hydrocephalus, a condition characterized by the abnormal accumulation of cerebrospinal fluid in the ventricles of the brain. Despite its efficacy, this procedure is associated with various complications, among which distal catheter obstruction poses significant challenges. This study aimed to evaluate the effectiveness of the 'falciform technique' in laparoscopic revision of distal catheter obstructions, offering a novel approach to mitigate this prevalent issue.

Materials and methods

This study retrospectively analyzed 28 patients with VP shunt distal catheter obstructions who underwent laparoscopy-assisted shunt revision between January 2016 and June 2022. All of these were done using the 'falciform technique' with the fixation of the distal catheter to the falciform ligament in supra-hepatic space.

Results

The most common etiology of primary shunt surgery was hydrocephalus, followed by intracranial hemorrhage (42.9%) and traumatic brain injury (32.1%). Normal pressure hydrocephalus occurs in 14.3% of cases. Fifteen patients (53.6%) required revision surgery within 1 year of index surgery. Thirteen patients (46.4%) underwent revision surgery more than 1 year after the index surgery, either as a first revision or subsequent revision. The average surgery time was 32.1±14.7 min and hospital stay was 4.2±1.8 days. After a mean follow-up period of at 20.3±8.7 months, except for three patients who died from other causes (two patients due to pneumonia and one due to exhaustion), there were no shunt-related complications in the remaining 25 patients.

Conclusions

Laparoscopy with the application of 'falciform technique' is a safe and highly effective method in distal catheter obstruction revision following VP shunt.

Cerebrospinal Fluid Shunt Reinfection and Malfunction in Ecuadorian Children with Different Reshunting Criteria After Infection. "Is It Just One Shunt After Another?"

OBJECTIVE

There is no firm evidence regarding cerebrospinal fluid (CSF) shunt reimplantation after infection in the pediatric population. The purpose of this study was to compare different criteria and analyze new shunt failure.

METHODS

A cross-sectional retrospective multicenter study was performed over 6 years to study patients and each infected shunt at diagnosis, reimplantation, and after reimplantation. The patients were divided into 2 groups: group 1 (G1), reimplantation after negative serial CSF cultures during antibiotic treatment; group 2 (G2), reimplantation after negative serial pancultures after completion of antibiotics. The differences were measured with Mann-Whitney and Χ2 tests; multivariate analysis and associations were calculated using odds ratios (ORs) based on logistic regression.

RESULTS

There were 137 shunt infection events in 110 patients: 28 events in G1 and 109 in G2. Significant differences were observed in the diagnosis and reimplantation. Reimplantation dysfunction in G1 was 16 (55.17%) versus 30 (27.78%) in G2 (P = 0.006). The risk of shunt malfunction after reimplantation increased for G1 reimplantation criteria (P = 0.018; OR, 3.34; confidence interval [CI], 1.23-9.05): pleocytosis at diagnosis >17 cells (P = 0.036; OR, 2.41; CI, 1.06-5.47), CSF proteins at diagnosis >182 mg/dL (P = 0.049; OR, 2.21; CI, 1.00-4.89).

CONCLUSIONS

G2 reimplantation criteria were related to improved pleocytosis, CSF proteins, and blood neutrophils compared with G1. Mechanical and infectious dysfunction of the new shunt was 3 times more prevalent in G1 than in G2, considering the differences between the groups at diagnosis. Increased parameters of infection at diagnosis were associated with future malfunction more than parameters before reimplantation in both groups.

G, Gunasekaran A, Chandar V. Comparison of Optic Nerve Sheath Diameter (ONSD) Measurements Obtained from USG Before and After Placement of Ventriculoperitoneal Shunt in Obstructive Hydrocephalus as a Surrogate Marker for Adequacy of Shunt Function: A Prospective Observational Study

Introduction  Optic nerve sheath diameter (ONSD) measured using ultrasonography has been widely used as a surrogate marker of elevated intracranial pressure. However, literature is sparse on the correlation between ONSD and ventriculoperitoneal (VP) shunt function, especially in adults with hydrocephalus. Our study was designed to assess the correlation between ONSD measured using ultrasonography before and 12 hours after VP shunt placement and the success of VP shunt placement assessed using computed tomography (CT) of the brain. Materials and Methods  Fifty-one patients between 16 and 60 years of age, with obstructive hydrocephalus scheduled for VP shunt surgery were included in this prospective, observational study. ONSD measurements were obtained from both eyes prior to induction of anesthesia, immediately after the surgery, and at 6, 12, and 24 hours after the surgery. An average of three readings was obtained from each eye. Cerebrospinal fluid (CSF) opening pressure was noted after entry into the lateral ventricle. Noncontrast CT (NCCT) brain was obtained 12 hours after the surgery and was interpreted by the same neurosurgeon for signs of successful VP shunt placement. Results  There was a significant reduction in ONSD in the postoperative period compared to ONSD measured preoperatively. The average ONSD (mean ± standard deviation) measured prior to induction of anesthesia, immediately after the surgery, and at 6, 12, and 24 hours after the surgery was 5.71 ± 0.95, 5.20 ± 0.84, 5.06 ± 0.79, 4.90 ± 0.79, and 4.76 ± 0.75 mm, respectively. The mean CSF opening pressure was 19.6 ± 6.9 mm Hg. Postoperative NCCT brain revealed misplacement of the shunt tip in only one patient. Conclusion  ONSD measured using ultrasonography may be used as a reliable indicator of VP shunt function in adults with obstructive hydrocephalus.

Structural and functional connectivity in hydrocephalus: a scoping review

Optimizing the treatment of hydrocephalus remains a major challenge in adult and pediatric neurosurgery. Currently, clinical treatment relies heavily on anatomic imaging of ventricular size and clinical presentation. The emergence of functional and structural brain connectivity imaging has provided the basis for a new paradigm in the management of hydrocephalus. Here we review the pertinent advances in this field. Following PRISMA-ScR guidelines for scoping reviews, we searched PubMed for relevant literature from 1994 to April 2023 using hydrocephalus and MRI-related terms. Included articles reported original MRI data on human subjects with hydrocephalus, while excluding non-English or pre-1994 publications that didn't match the study framework. The review identified 44 studies that investigated functional and/or structural connectivity using various MRI techniques across different hydrocephalus populations. While there is significant heterogeneity in imaging technology and connectivity analysis, there is broad consensus in the literature that 1) hydrocephalus is associated with disruption of functional and structural connectivity, 2) this disruption in cerebral connectivity can be further associated with neurologic compromise 3) timely treatment of hydrocephalus restores both cerebral connectivity and neurologic compromise. The robustness and consistency of these findings vary as a function of patient age, hydrocephalus etiology, and the connectivity region of interest studied. Functional and structural brain connectivity imaging shows potential as an imaging biomarker that may facilitate optimization of hydrocephalus treatment. Future research should focus on standardizing regions of interest as well as identifying connectivity analysis most pertinent to clinical outcome.

Influence of age on the relation between body position and noninvasively acquired intracranial pulse waves

The capacitive measurement of the head's dielectric properties has been recently proposed as a noninvasive method for deriving surrogates of craniospinal compliance (CC), a parameter used in the evaluation of space-occupying neurological disorders. With the higher prevalence of such disorders in the older compared to the younger population, data on the head's dielectric properties of older healthy individuals would be of particularly high value before assessing pathologic changes. However, so far only measurements on young volunteers (< 30 years) were reported. In the present study, we have investigated the capacitively obtained electric signal known as W in older healthy individuals. Thirteen healthy subjects aged > 60 years were included in the study. W was acquired in the resting state (supine horizontal position), and during head-up and head-down tilting. AMP, the peak-to-valley amplitude of W related to cardiac action, was extracted from W. AMP was higher in this older cohort compared to the previously investigated younger one (0°: 5965 ± 1677 arbitrary units (au)). During head-up tilting, AMP decreased (+ 60°: 4446 ± 1620 au, P < 0.001), whereas it increased during head-down tilting (- 30°: 7600 ± 2123 au, P < 0.001), as also observed in the younger cohort. Our observation that AMP, a metric potentially reflective of CC, is higher in the older compared to the younger cohort aligns with the expected decrease of CC with age. Furthermore, the robustness of AMP is reinforced by the consistent relative changes observed during tilt testing in both cohorts.

Classification of Chronic Hydrocephalus in Adults: A Systematic Review and Analysis

BACKGROUND

Chronic hydrocephalus in adults (CHiA) includes all nonacute forms of hydrocephalus occurring in adulthood. It covers a spectrum of disorders. Some of these have relatively agreed on definitions, while others are less well characterized. The existing medical classification systems lack adequate structure and are neither clinically oriented nor easy to use, which severely hampers research and clinical care efforts.

METHODS

A systematic literature review and data analysis were performed, focusing on the terms "adult hydrocephalus" and "classification," using the PubMed, Scopus, and Cochrane Library databases. Data on terminology, definitions, patient demographics, symptom duration, and clinical presentations were extracted, analyzed, and compiled. A Delphi process was followed to define CHiA disorders.

RESULTS

A total of 33 studies collectively used 48 terms to define various CHiA disorders. Different terms were used to describe similar conditions. CHiA disorders were found to be clustered into 7 distinctive clinical entities based on the clinical characteristics.

CONCLUSIONS

An evidence-based new clinical classification for CHiA is suggested. Our review identified gaps in knowledge and areas for further research.

Do P-glycoprotein Medications Alter the Risk of Ventriculoperitoneal Shunt in Adults with Hydrocephalus?

Hydrocephalus is a disorder caused by excess fluid accumulation in the brain and results in brain damage with consequent cognitive and physical problems. This condition has no cure; the only treatment is brain surgery. Experimental data indicate that P-glycoprotein (P-gp) plays a crucial role in the pathogenesis of hydrocephalus due to its function in clearing macromolecules from the brain. Numerous medications frequently used are classified as P-gp inducers or inhibitors, and comprehending their effects may aid in attaining improved patient outcomes. Therefore, in this single-center retrospective study, we examined the risk of the need for ventriculoperitoneal shunt placement over 10 years among 4588 adult patients with hydrocephalus not exposed to any P-gp inhibitors/inducers or exclusively exposed to either P-gp inhibitors or inducers. Our analysis shows that patients exposed to P-gp inhibitors had a 3.2 times higher risk of requiring ventriculoperitoneal shunt surgery (P < .0001). In contrast, the relative risk was not significantly affected (P = .07) among those exposed to P-gp inducers. Our findings indicate the need for caution when prescribing P-gp inhibitors to patients with hydrocephalus. Additional studies using larger cohorts are required to confirm whether P-gp inducers in patients with hydrocephalus can mitigate the risk of ventriculoperitoneal shunt.

Comparing motor development in children with hydrocephalus after treatment with ventriculoperitoneal shunt and endoscopic third ventriculostomy: a cross-sectional study

Introduction

Ventriculoperitoneal shunt insertion (VPSI) and endoscopic third ventriculostomy (ETV) are the major procedures for treating pediatric hydrocephalus. However, studies comparing motor development following the two treatments are limited.

Objective

We aimed to determine motor development outcomes in children with hydrocephalus up to 2 years of age after undergoing VPSI or ETV, to identify which surgical approach yields better motor outcomes and may be more effective for Malawian children.

Methods

This was a cross-sectional study where we recruited two groups of participants: one group consisted of children with hydrocephalus treated with VP shunt whilst the other group were treated with ETV, at least 6 months prior to this study. Participants were identified from the hospital records and were called to come for neurodevelopmental assessment using the Malawi Development Assessment Tool (MDAT).

Results

A total 152 children treated for hydrocephalus within an 18-month period met the inclusion criteria. Upon follow up and tracing, we recruited 25 children who had been treated: 12 had VPSI and 13 had ETV. MDAT revealed delays in both assessed motor domains: 19 out of the 25 children had delayed gross motor whilst 16 of 25 had delayed fine motor development. There was no significant difference between the shunted and the ETV groups.

Conclusion

Children with hydrocephalus demonstrate delays in motor development six to 18 months after treatment with either VPSI or ETV. This may necessitate early and prolonged intensive rehabilitation to restore motor function after surgery. Long-term follow-up studies with bigger sample sizes are required to detect the effect of the two treatment approaches.

Engineering innovations in medicine and biology: Revolutionizing patient care through mechanical solutions

The overlap between mechanical engineering and medicine is expanding more and more over the years. Engineers are now using their expertise to design and create functional biomaterials and are continually collaborating with physicians to improve patient health. In this review, we explore the state of scientific knowledge in the areas of biomaterials, biomechanics, nanomechanics, and computational fluid dynamics (CFD) in relation to the pharmaceutical and medical industry. Focusing on current research and breakthroughs, we provide an overview of how these fields are being used to create new technologies for medical treatments of human patients. Barriers and constraints in these fields, as well as ways to overcome them, are also described in this review. Finally, the potential for future advances in biomaterials to fundamentally change the current approach to medicine and biology is also discussed.

Prenatal Diagnosis of Fetal Aqueductal Stenosis: A Multicenter Prospective Observational Study through the North American Fetal Therapy Network

INTRODUCTION

A critical component of an evidence-based reassessment of in-utero intervention for fetal aqueductal stenosis (fetal AS) is determining if the prenatal diagnosis can be accurately made at a gestational age amenable to in-utero intervention.

METHODS

A multicenter, prospective, observational study was conducted through the North American Fetal Therapy Network (NAFTNet). Pregnancies complicated by severe central nervous system (CNS) ventriculomegaly (lateral ventricle diameter >15 mm) not secondary to a primary diagnosis (myelomeningocele, encephalocele, etc.) were recruited at diagnosis. Imaging and laboratory findings were recorded in an online REDCap database. After evaluation, investigators were asked to render their degree of confidence in the diagnosis of fetal AS. The prenatal diagnosis was compared to the postnatal diagnosis obtained through neonatal neuroimaging. Performance characteristics of ultrasound and magnetic resonance imaging (MRI) were calculated, as was the mean gestational age at diagnosis.

RESULTS

Between April 2015 and October 2022, eleven NAFTNet centers contributed 64 subjects with severe fetal CNS ventriculomegaly. Of these, 56 had both prenatal and postnatal diagnoses recorded. Ultrasound revealed 32 fetal AS true positives, 4 false positives, 7 false negatives, and 13 true negatives, rendering a sensitivity of 0.82, a specificity of 0.76, a positive predictive value of 0.89, and a negative predictive value of 0.65. The mean gestational age at diagnosis by ultrasound was 25.5 weeks (std +/- 4.7 weeks). The proportion of agreement (true positive + true negative/n) was highest at 24 weeks gestation. For fetal MRI (n = 35), the sensitivity for fetal AS was 0.95, specificity was 0.69, positive predictive value was 0.84, and negative predictive value was 0.90. MRI was performed at 25 weeks on average.

CONCLUSION

The prenatal diagnosis of fetal AS can be made with accuracy at a gestational age potentially amenable to in-utero intervention. Only 7% of subjects were incorrectly diagnosed prenatally with fetal AS by ultrasound and 11% by MRI. Diagnostic accuracy of fetal AS will likely improve with increased experience.

Congenital Pediatric Hydrocephalus in the Brazilian Public Health System: The Reality of a Middle-Income Country in the Past 13 Years

BACKGROUND

Congenital hydrocephalus is a significant challenge in neurosurgery, particularly in resource-limited settings. This study focuses on the congenital hydrocephalus in Brazil, a developing country, over the past 13 years.

METHODS

This study is a retrospective analysis of congenital hydrocephalus treatment and outcomes using data records on DATASUS from January 2008 to July 2021. Demographics, cost of hospitalizations, amount paid to professionals, mortality, and mean length of stay (LOS) were analyzed. Statistical analysis was conducted to determine significant associations between these indicators and pediatric hydrocephalus.

RESULTS

DATASUS recorded 8493 cases of congenital hydrocephalus in the studied period, with a prevalence of 24.28 per 100,000 newborns, mostly linked to spina bifida. Congenital hydrocephalus caused 60.83 ± 13.98 neonatal deaths per year, with the highest rate among 32-36 weeks gestational age. Acquired hydrocephalus led to 1063 infant deaths, whereas congenital hydrocephalus resulted in 3122 deaths, with no clear trend by the years. White infants had the highest mortality. A total of 33,184 shunt procedures were performed, with an average cost of $715.37 per procedure. The mortality model showed no significant effects of cost or professionals' salary, but a significant effect of LOS on hospitalization costs was observed.

CONCLUSIONS

Pediatric hydrocephalus in Brazil's public health system is a significant burden. Congenital hydrocephalus prevalence and mortality emphasize the need for early diagnosis and treatment. Early diagnosis, prenatal care, and adequate resources are crucial. This study offers insights into congenital hydrocephalus, highlighting challenges and future directions for improved care.

Association between altered white matter networks and post operative ventricle volume in shunt-treated pediatric hydrocephalus

OBJECTIVE

The objective of this study was to use probabilistic tractography in combination with white matter microstructure metrics to characterize differences in white matter networks between shunt-treated pediatric hydrocephalus patients relative to healthy controls. We were also able to explore the relationship between these white matter networks and postoperative ventricle volume.

METHODS

Network-based statistics was used in combination with whole-brain probabilistic tractography to determine dysregulated white matter networks in a sample of patients with pediatric hydrocephalus (n = 8), relative to controls (n = 36). Metrics such as streamline count (SC), as well as the mean of the fractional anisotropy along a tract, axial diffusivity (AD), mean diffusivity (MD), and radial diffusivity (RD) were assessed. In networks that were found to be significantly different for patients with hydrocephalus, tracts were evaluated to assess their relationship with postoperative lateral ventricle volume.

RESULTS

Patients with pediatric hydrocephalus had various networks that were either upregulated or downregulated relative to controls across all white matter measures. Predominately, network dysregulation occurred in tracts involving structures located outside of the frontal lobe. Furthermore tracts with values suggesting decreased white matter integrity were not only found between subcortical structures, but also cortical structures. While there were various tracts with white matter metrics that were initially predicted by lateral ventricle volume, only two tracts remained significant following multiple comparisons.

CONCLUSIONS

This cross-sectional study in pediatric patients with hydrocephalus and healthy controls demonstrated using whole-brain probabilistic tractography that there are various networks with dysregulated white matter integrity in hydrocephalus patients relative to controls. These dysregulated networks have tracts connecting structures throughout the brain, and the regions were predominately located centrally and posteriorly. Postoperative ventricle volume did not predict the white matter integrity of many tracts. Future studies with larger sample sizes are needed to further understand these results.

Racial and ethnic differences in infant survival for hydrocephaly-Texas, 1999-2017

BACKGROUND

Congenital hydrocephaly, an abnormal accumulation of fluid within the ventricular spaces at birth, can cause disability or death if untreated. Limited information is available about survival of infants born with hydrocephaly in Texas. Therefore, the purpose of the study was to calculate survival estimates among infants born with hydrocephaly without spina bifida in Texas.

METHODS

A cohort of live-born infants delivered during 1999-2017 with congenital hydrocephaly without spina bifida was identified from the Texas Birth Defects Registry. Deaths within 1 year of delivery were identified using vital and medical records. One-year infant survival estimates were generated for multiple descriptive characteristics using the Kaplan-Meier method. Crude hazard ratios (HRs) for one-year survival among infants with congenital hydrocephaly by maternal and infant characteristics and adjusted HRs for maternal race and ethnicity were estimated using Cox proportional hazard models.

RESULTS

Among 5709 infants born with congenital hydrocephaly without spina bifida, 4681 (82%) survived the first year. The following characteristics were associated with infant survival: maternal race and ethnicity, clinical classification (e.g., chromosomal or syndromic), preterm birth, birth weight, birth year, and maternal education. In the multivariable Cox proportional hazards model, differences in survival were observed by maternal race and ethnicity after adjustment for other maternal and infant characteristics. Infants of non-Hispanic Black (HR: 1.28, 95% CI: 1.04-1.58) and Hispanic (HR: 1.31, 95% CI: 1.12-1.54) women had increased risk for mortality, compared with infants of non-Hispanic White women.

CONCLUSIONS

This study showed infant survival among a Texas cohort differed by maternal race and ethnicity, clinical classification, gestational age, birth weight, birth year, and maternal education in infants with congenital hydrocephaly without spina bifida. Findings confirm that mortality continues to be common among infants with hydrocephaly without spina bifida. Additional research is needed to identify other risk factors of mortality risk.

Polyvinylpyrrolidone-coated catheters decrease choroid plexus adhesion and improve flow/pressure performance in an in vitro model of hydrocephalus

PURPOSE

Proximal catheter obstruction is the leading cause of ventricular shunt failure in pediatric patients. Our aim is to evaluate various types of shunt catheters to assess in vitro cellular adhesion and obstruction.

METHODS

Four catheter types were tested: (1) antibiotic and impregnated, (2) barium-stripe polyvinylpyrrolidone coated (PVP), (3) barium-stripe, and (4) barium-impregnated. Catheters were seeded with choroid plexus epithelial cells to test cellular adhesion and inoculated with the same cells to test flow/pressure performance under choroid plexus growth conditions. Ventricular catheters were placed into a three-dimensional printed phantom ventricular replicating system through which artificial cerebrospinal fluid (CSF) was pumped. Differential pressure sensors were used to measure catheter performance.

RESULTS

PVP catheters had the lowest median cell attachment (10 cells) compared to antibiotic-impregnated (230 cells), barium stripe (513 cells), and barium-impregnated (146 cells) catheters after culture (p < 0.01). In addition, PVP catheters (- 0.247 cm H2O) and antibiotic-impregnated (- 1.15 cm H2O) catheters had significantly lower pressure in the phantom ventricular system compared to the barium stripe (0.167 cm H2O) and barium-impregnated (0.618 cm H2O; p < 0.01) catheters.

CONCLUSIONS

PVP catheters showed less cellular adhesion and, together with antibiotic-impregnated catheters, required less differential pressure to maintain a consistent flow. Our findings suggest clinical relevance for using PVP ventricular catheters in patients with recurrent catheter obstruction by choroid plexus.

Paediatric ventriculoperitoneal shunt failures: 12-year experience from a Singapore children's hospital

PURPOSE

Cerebrospinal fluid (CSF) shunt failures in children are devastating. The primary aims of this study are to, firstly, review our institutional series of ventriculoperitoneal shunt (VPS) insertions and identify factors associated with shunt failure.

METHODS

This is a single-institution, retrospective study conducted over a 12-year period. All patients under 18 years old with VPS inserted were included. Variables of interest such as patient characteristics, hydrocephalus aetiology, shunt implant details, and outcomes were subjected to statistical analyses.

RESULTS

A total of 214 VPS patients were selected for this study. The mean age at VPS insertion was 6 months with a mean follow-up duration of 44 months. The most common type of hydrocephalus was obstructive (n = 142, 66.4%), and the most frequent aetiology was tumour-related (n = 66, 30.8%). The 30-day shunt failure rate was 9.3%: 9 infections (4.2%), 7 occlusions (3.3%), and 4 others (1.9%). After multivariable analysis, only recent central nervous system (CNS) infection prior to VPS insertion remained significant (OR 15.4 (1.3-175), p = 0.028).

CONCLUSION

This is the first, large-scale local study focused on the shunt failure in Singaporean children. Significant findings in our study demonstrate that recently treated CNS infection is a factor associated with 30-day shunt failure while the values of CSF constituents were not contributory.

Dual function of the choroid plexus: Cerebrospinal fluid production and control of brain ion homeostasis

The choroid plexus is a small monolayered epithelium located in the brain ventricles and serves to secrete the cerebrospinal fluid (CSF) that envelops the brain and fills the central ventricles. The CSF secretion is sustained with a concerted effort of a range of membrane transporters located in a polarized fashion in this tissue. Prominent amongst these are the Na+/K+-ATPase, the Na+,K+,2Cl- cotransporter (NKCC1), and several HCO3- transporters, which together support the net transepithelial transport of the major electrolytes, Na+ and Cl-, and thus drive the CSF secretion. The choroid plexus, in addition, serves an important role in keeping the CSF K+ concentration at a level compatible with normal brain function. The choroid plexus Na+/K+-ATPase represents a key factor in the barrier-mediated control of the CSF K+ homeostasis, as it increases its K+ uptake activity when faced with elevated extracellular K+ ([K+]o). In certain developmental or pathological conditions, the NKCC1 may revert its net transport direction to contribute to CSF K+ homeostasis. The choroid plexus ion transport machinery thus serves dual, yet interconnected, functions with its contribution to electrolyte and fluid secretion in combination with its control of brain K+ levels.

Ventriculoperitoneal Shunt Surgery in Brunei Darussalam: A Population-Based Perspective

Objective  Ventriculoperitoneal shunt surgery is commonly performed to treat hydrocephalus. We aimed to characterize the demographics, complications, and outcomes of patients who underwent ventriculoperitoneal shunt surgery in Brunei Darussalam. Materials and Methods  We conducted a retrospective study on patients who underwent ventriculoperitoneal shunt surgery at the Neurosurgery Department of the Raja Isteri Pengiran Anak Saleha Hospital and Brunei Neuroscience Stroke and Rehabilitation Centre between January 2015 and June 2020. Statistical Analysis  All statistical analyses were performed using the Statistical Package for the Social Sciences version 20 (IBM Corporation, Armonk, New York, United States). The χ 2 test, Student's t -test, and Mann-Whitney U test were performed for nominal, normally, and non-normally distributed variables, respectively. Multivariate logistic regression was used to assess the predictors of complications and shunt failure. Results  Fifty-three patients with a median age of 33 (interquartile range, 4-49) years were included. A total of 53 shunt operations were performed: 18 in the pediatric population and 35 in adults. The overall complication rate was 22.6%. Infection was the most common (9.4%) complication, with coagulase-negative staphylococci being the common organism causing the infection. The shunt failure rate (defined as removal or revision) was 20.8%. Univariate and multivariate analyses did not identify factors associated with complications or shunt failure. Conclusion  Ventriculoperitoneal shunt surgery, a common and technically non-demanding neurosurgical procedure, is associated with significant complications. We highlighted that shunt infection remains a concern and advocate practices to negate this risk.

Comparison of External Ventricular Drains with Ventricular Access Devices for the Emergency Management of Adult Hydrocephalus

OBJECTIVE

We compared external ventricular drains (EVDs) with percutaneous continuous cerebrospinal fluid (CSF) drainage via ventricular access devices (VADs) for the acute management of hydrocephalus in adults.

METHODS

This was a retrospective review of all ventricular drains inserted for a new diagnosis of hydrocephalus into noninfected CSF over four years. We compared infection rates, return to theatre, and patient outcome between EVDs and VADs. We explored the effect of duration of drainage, frequency of sampling, hydrocephalus aetiology, and catheter location on these outcomes using multivariable logistic regression modelling.

RESULTS

We included 179 drains (76 EVDs and 103 VADs). EVDs were associated with a higher rate of unplanned return to theatre for replacement or revision (27/76, 36%, vs. 4/103, 4%, OR: 13.4 95%CI: 4.3-55.8). However, infection rates were higher in VADs (13/103, 13% vs. 5/76, 7%, OR: 2.0, 95%CI: 0.65-7.7). EVDs were 91% antibiotic impregnated whereas VADs were 98% nonimpregnated. In multivariable analysis, infection was associated with duration of drainage (median: 11 days prior to infection for infected drains vs. 7 days total for noninfected drains), but not drain type (VADs vs. EVDs OR: 1.6, 95%CI: 0.5-6).

CONCLUSIONS

EVDs had a higher rate of unplanned revisions but a lower infection rate compared to VADs. However, in multivariable analysis choice of drain type was not associated with infection. We suggest a prospective comparison of antibiotic impregnated VADs and EVDs using similar sampling protocols to assess whether VADs or EVDs for acute hydrocephalus have a lower overall complication rate.