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Goertz L, Pieczewski J, Zopfs D, Kabbasch C, Timmer M, Goldbrunner R, Wetzel C. Prospective evaluation of flow-regulated valves for idiopathic normal pressure hydrocephalus: 1-year results. J Clin Neurosci 2024; 124:94-101. [PMID: 38678972 DOI: 10.1016/j.jocn.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/16/2024] [Accepted: 04/19/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVE Overdrainage and frequent reprogramming are common problems with programmable valves after ventriculoperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (iNPH). Non-adjustable, flow-regulated valves offer a potential solution to these problems, but there is limited data on their efficacy. This study will evaluate neurological improvement and overdrainage rates within one year of treatment with a flow-regulated valve. PATIENTS AND METHODS This prospective study analyzes 45 iNPH patients (median age: 73 years) treated with a flow-regulated valve. Clinical evaluations were performed at baseline, postoperatively, and at 3, 6, and 12 months after surgery. The primary efficacy endpoint was improvement of at least 5 points on the iNPH grading scale at follow-up. The safety endpoint was radiographic evidence of overdrainage. RESULTS All patients presented with gait disturbance, 35 (78 %) had cognitive impairment, and 35 (78 %) had urinary incontinence. The median duration of symptoms was 24 months. The total iNPH score improved in 33/41 (81 %) at 3 months, in 29/34 (85 %) at 6 months, and in 22/29 (64 %) at 12 months. Overall, 40/45 (89 %) patients had a significant improvement on the iNPH scale. Secondary worsening of symptoms after initial improvement was observed in 5 (11 %) patients. Overdrainage occurred in one patient (2 %) requiring surgical evacuation. CONCLUSION Treatment of iNPH patients with flow-regulated valves resulted in a good neurological outcome with minimal rates of overdrainage. These results are encouraging and justify the clinical use of these valve types.
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Affiliation(s)
- Lukas Goertz
- Center for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany; Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
| | - Julia Pieczewski
- Center for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - David Zopfs
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Marco Timmer
- Center for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Center for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Christian Wetzel
- Center for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
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Panagopoulos D, Gavra M, Boviatsis E, Korfias S, Themistocleous M. Chronic Pediatric Headache as a Manifestation of Shunt Over-Drainage and Slit Ventricle Syndrome in Patients Harboring a Cerebrospinal Fluid Diversion System: A Narrative Literature Review. CHILDREN (BASEL, SWITZERLAND) 2024; 11:596. [PMID: 38790591 PMCID: PMC11120100 DOI: 10.3390/children11050596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/19/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
The main subject of the current review is a specific subtype of headache, which is related to shunt over-drainage and slit ventricle syndrome, in pediatric patients harboring an implanted shunt device for the management of hydrocephalus. This clinical entity, along with its impairment regarding the quality of life of the affected individuals, is generally underestimated. This is partly due to the absence of universally agreed-upon diagnostic criteria, as well as due to a misunderstanding of the interactions among the implicated pathophysiological mechanisms. A lot of attempts have been performed to propose an integrative model, aiming at the determination of all the offending mechanisms of the shunt over-drainage syndrome, as well as the determination of all the clinical characteristics and related symptomatology that accompany these secondary headaches. This subcategory of headache, named postural dependent headache, can be associated with nausea, vomiting, and/or radiological signs of slim ventricles and/or subdural collections. The ultimate goal of our review is to draw clinicians' attention, especially that of those that are managing pediatric patients with permanent, long-standing, ventriculoperitoneal, or, less commonly, ventriculoatrial shunts. We attempted to elucidate all clinical and neurological characteristics that are inherently related to this type of headache, as well as to highlight the current management options. This specific subgroup of patients may eventually suffer from severe, intractable headaches, which may negatively impair their quality of daily living. In the absence of any other clinical condition that could be incriminated as the cause of the headache, shunt over-drainage should not be overlooked. On the contrary, it should be seriously taken into consideration, and its management should be added to the therapeutic armamentarium of such cases, which are difficult to be handled.
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Affiliation(s)
| | - Maro Gavra
- Neuro-Radiology Department, Pediatric Hospital of Athens, 45701 Athens, Greece;
| | - Efstathios Boviatsis
- 2nd University Neurosurgical Department, Medical School, General Hospital of Athens ‘Attikon’, University of Athens, 12462 Athens, Greece;
| | - Stefanos Korfias
- 1st University Neurosurgical Department, Medical School, General Hospital of Athens ‘Evangelismos’, University of Athens, 10676 Athens, Greece;
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Shiferaw MY, Teklemariam TL, Wondimagegnewu EZ, Gebrewahd DT, Yesuf EF, Mekuria BH, Abelti SB. Diffuse subarachnoid hemorrhage following ventriculo-peritoneal shunt insertion for acute obstructive hydrocephalus from large glomus jugulare tumor: case report. Front Surg 2024; 11:1353400. [PMID: 38645509 PMCID: PMC11027019 DOI: 10.3389/fsurg.2024.1353400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/19/2024] [Indexed: 04/23/2024] Open
Abstract
Background Glomus jugulare tumors (GJTs) are rare intra-cranial tumors. Commonly, these lesions present with cranial nerve palsies, headaches, and hydrocephalus. Rarely, GJTs present with spontaneous subarachnoid hemorrhage. However, there has never been a report of diffuse subarachnoid hemorrhage following ventriculoperitoneal shunt insertion in a patient who developed hydrocephalus secondary to any brain tumor in general or glomus jugulare tumors in particular. Observation The authors presented an extremely rare complication of diffuse subarachnoid hemorrhage following the insertion of a ventriculoperitoneal shunt (VPS) in a 61-year-old female patient who was diagnosed to have both clinical and radiologic features of acute obstructive hydrocephalus secondary to a highly vascular huge glomus jugulare tumor. Conclusion Subarachnoid hemorrhage following ventriculoperitoneal shunt insertion for hydrocephalus caused by a mass lesion is an extremely rare complication. Preoperative CT angiography should be strongly considered to look for the associated vascular malformations in extremely vascularized mass lesions. Given the not ubiquitous availability of all therapeutic options for GJTs, especially in low and middle income settings contributes for the poor outcome of GJTs and it fosters a global neurosurgery agenda.
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Affiliation(s)
| | | | | | - Dejen Tekiea Gebrewahd
- Department of surgery, Neurosurgery Division, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ermias Fikru Yesuf
- Department of surgery, Neurosurgery Division, Addis Ababa University, Addis Ababa, Ethiopia
| | - Bereket Hailu Mekuria
- Department of surgery, Neurosurgery Division, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sebboona Baisa Abelti
- Department of surgery, Neurosurgery Division, Addis Ababa University, Addis Ababa, Ethiopia
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Zipfel J, Kohlmann-Dell’Acqua C, Noell S, Trakolis L. 17 years of experience with shunt systems in normal pressure hydrocephalus - From differential pressure to gravitational valves. World Neurosurg X 2024; 22:100293. [PMID: 38450246 PMCID: PMC10914590 DOI: 10.1016/j.wnsx.2024.100293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 02/20/2024] [Indexed: 03/08/2024] Open
Abstract
Objective Complication rate of shunting for normal pressure hydrocephalus (NPH) has significantly improved over the last decades. Especially the use of overdrainage protection has reduced the incidence of subdural hematoma and collections. However, gravitational valves were associated with other complications of shunt dysfunction. We present our 17 years of experience with patients with normal pressure hydrocephalus who changed from a differential pressure valve to a gravitational valve system. Methods We retrospectively identified all patients with the diagnosis of normal pressure hydrocephalus, in whom primary shunt implantation was performed between 2004 and 2020. Shunt implantation was performed as per our internal standard. Review of imaging, charts and patient reports was performed. Results In total, 409 patients were included in the analysis. Mean age was 73.0 ± 7.1years. Between 2004 and 2010, predominantly Hakim valves (n = 100, 24.4%) were implanted, whilst from 2009 until 2020, proGAV valves (n = 296, 72.4%) were used. Mean follow-up was 8.9 ± 4.5 years. Initial subjective improvement of symptoms was reported in 69.9%, whilst this number decreased at the last follow-up to 29.8%. No significant differences were observed between the valves in the frequency of surgery for subdural hematoma. Shunt assistant implantation was performed in 17% of patients with Hakim valve, in 9.5% of patients with proGAV, a shunt assistant was added. Shunt obstruction was significantly higher in proGAV valves (p < 0.001). Conclusions Our findings confirm the observation of frequent overdrainage in shunts without anti-siphon/gravitational component. Gravitational valves on the other hand may be associated with more obstruction.
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Affiliation(s)
- Julian Zipfel
- Department of Neurosurgery, University Hospital Tuebingen, Germany
- Centre for Clinical Studies, Neuropsychiatric Study Centre, University Hospital Tuebingen, Germany
| | - Cristina Kohlmann-Dell’Acqua
- Department of Neurosurgery, University Hospital Tuebingen, Germany
- Centre for Clinical Studies, Neuropsychiatric Study Centre, University Hospital Tuebingen, Germany
| | - Susan Noell
- Department of Neurosurgery, University Hospital Tuebingen, Germany
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Chaisawasthomrong C, Saetia K. Bifrontal-Parietal Ratio: A Novel Risk Factor for Cerebrospinal Fluid Overdrainage after Ventriculoperitoneal Shunting. Asian J Neurosurg 2024; 19:37-43. [PMID: 38751399 PMCID: PMC11093634 DOI: 10.1055/s-0043-1775729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
Objective This study aimed to examine potential risk factors associated with cerebrospinal fluid overdrainage after ventriculoperitoneal (VP) shunting. Materials and Methods We retrospectively examined the medical records of hydrocephalus patients who underwent VP shunting at a single institution between January 2011 and December 2017 and had a minimum 3-year follow-up. Variables studied included age, gender, hydrocephalus etiology, symptoms, shunt valve, ventricular catheter entry point, and neurosurgical history, including history of external ventricular drainage. Radiographic variables included Evans index, bicaudate index, callosal angle, measurements of frontal lobe thickness, and bifrontal-parietal ratio. Results Among the 182 study patients, 11 experienced overdrainage. Age, gender, etiology, symptoms, and surgical history did not significantly differ between patients who experienced overdrainage and those who did not. Evans index, bicaudate index, and callosal angle did not significantly differ between the groups. Measurements of frontal lobe thickness and bifrontal--parietal ratio were significantly lower in the overdrainage group. Conclusion Bifrontal-parietal ratio may be useful to predict overdrainage after VP shunt surgery.
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Affiliation(s)
- Chonnawee Chaisawasthomrong
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kriangsak Saetia
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Li C, Li M, Wang Y, Li S, Cong L, Ma W. A controlled lumbar puncture procedure improves the safety of lumbar puncture. Front Neurosci 2023; 17:1304150. [PMID: 38116072 PMCID: PMC10728282 DOI: 10.3389/fnins.2023.1304150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/21/2023] [Indexed: 12/21/2023] Open
Abstract
Background In order to improve the safety of lumbar puncture (LP), we designed a new type of LP needle, that is, an integrated and controlled LP needle, which can actively and accurately control the flow rate and retention of cerebrospinal fluid (CSF) during puncture, so as to achieve a controlled LP procedure. Objective To evaluate whether a controlled LP procedure can improve the comfort of LP and reduce the risk of complications associated with LP. Methods Patients requiring LP (n = 63) were pierced with an integrated and controlled LP needle or a conventional LP needle. The differences in vital signs, symptom score, comfort, operation time, CSF loss, CSF pressure fluctuation and back pain before and after puncture were analyzed. Results An integrated and controlled LP needle (n = 35) significantly improved patients' headache symptoms before and after puncture. In addition, a controlled LP procedure significantly reduced the amount of unnecessary CSF loss (p < 0.001), shortened the time of puncture (p < 0.001), improved patient comfort (p = 0.001) and reduced the incidence of back pain (p < 0.001). For patients with high intracranial pressure (HICP), the fluctuations in pressure of the CSF were also reduced while obtaining similar amounts of CSF (p = 0.009). Conclusion A controlled LP procedure avoids unnecessary CSF loss, prevents rapid fluctuations in CSF pressure in patients with HICP, and reduces the risks associated with LP.
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Affiliation(s)
- Chun Li
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Miaomiao Li
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yixian Wang
- Department of research and development, Medimicro (Tianjin) Medical Device Co., LTD, Tianjin, China
| | - Shaoyi Li
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Lin Cong
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Weining Ma
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
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Sanker V, Kundu M, El Kassem S, El Nouiri A, Emara M, Maaz ZA, Nazir A, Bekele BK, Uwishema O. Posttraumatic hydrocephalus: Recent advances and new therapeutic strategies. Health Sci Rep 2023; 6:e1713. [PMID: 38028696 PMCID: PMC10652704 DOI: 10.1002/hsr2.1713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 10/28/2023] [Accepted: 11/01/2023] [Indexed: 12/01/2023] Open
Abstract
Background Hydrocephalus or ventriculomegaly is a condition brought on by an overabundance of cerebrospinal fluid (CSF) in the ventricular system. The major contributor to posttraumatic hydrocephalus (PTH) is traumatic brain injuries (TBIs), especially in individuals with occupations set in industrial settings. A variety of criteria have been employed for the diagnosis of PTH, including the combination of neurological symptoms like nerve deficits and headache, as well as an initial improvement followed by a worsened relapse of altered consciousness and neurological deterioration, which is detected by computed tomography-brain imaging that reveals gradual ventriculomegaly. Aim In this article, we discuss and summarize briefly the current understandings and advancements in the management of PTH. Methods The available literature for this review was searched on various bibliographic databases using an individually verified, prespecified approach. The level of evidence of the included studies was considered as per the Centre for Evidence-Based Medicine recommendations. Results The commonly practiced current treatment modality involves shunting CSF but is often associated with complications and recurrence. The lack of a definitive management strategy for PTH warrants the utilization of novel and innovative modalities such as stem cell transplantations and antioxidative stress therapies. Conclusion One of the worst complications of a TBI is PTH, which has a high morbidity and mortality rate. Even though there hasn't been a successful method in stopping PTH from happening, hemorrhage-derived blood, and its metabolic by-products, like iron, hemoglobin, free radicals, thrombin, and red blood cells, may be potential targets for PTH hindrance and management. Also, using stem cell transplantations in animal models and antioxidative stress therapies in future studies can lower PTH occurrence and improve its outcome. Moreover, the integration of clinical trials and theoretical knowledge should be encouraged in future research projects to establish effective and updated management guidelines for PTH.
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Affiliation(s)
- Vivek Sanker
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Society of Brain Mapping and TherapeuticsLos AngelesCaliforniaUSA
| | - Mrinmoy Kundu
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Institute of Medical Sciences and SUM HospitalBhubaneswarIndia
| | - Sarah El Kassem
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Faculty of MedicineBeirut Arab UniversityBeirutLebanon
| | - Ahmad El Nouiri
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Faculty of MedicineBeirut Arab UniversityBeirutLebanon
| | - Mohamed Emara
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- College of MedicineUniversity of SharjahSharjahUnited Arab Emirates
| | - Zeina Al Maaz
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Faculty of MedicineBeirut Arab UniversityBeirutLebanon
| | - Abubakar Nazir
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
| | - Bezawit Kassahun Bekele
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- School of MedicineAddis Ababa UniversityAddis AbabaEthiopia
- Milken Institute of Public HealthGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Olivier Uwishema
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Department of medicineClinton Global Initiative UniversityNew YorkNew YorkUSA
- Faculty of MedicineKaradeniz Technical UniversityTrabzonTurkey
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Cai H, Yang F, Gao H, Huang K, Qin L, Wang R, Liu Y, Zhou L, Hao Z, Zhou D, Chen Q. Vascular risk factors for idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis. Front Neurol 2023; 14:1220473. [PMID: 37638192 PMCID: PMC10448702 DOI: 10.3389/fneur.2023.1220473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Objective Idiopathic normal-pressure hydrocephalus (iNPH) is a treatable cause of dementia; however, its etiology and pathogenesis remain poorly understood. The objective of this study was to investigate the prevalence and impact of vascular risk factors in patients with iNPH compared to a control cohort to better understand the potential mechanisms and preventive measures. Methods We systematically searched PubMed, Web of Science, Embase, and the Cochrane Library (from inception to December 20, 2022) for studies reporting vascular risk factors for the development of iNPH. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using random-effects models. Results After screening 1,462 articles, 11 case-control studies comprising 1,048 patients with iNPH and 79,668 cognitively unimpaired controls were included in the meta-analysis. Our data showed that hypertension (N = 991, OR = 2.30, 95% CI 1.64 to 3.23, I2= 64.0%), diabetes mellitus (DM) (N = 985, OR = 3.12, 95% CI 2.29 to 4.27, I2= 44.0%), coronary heart disease (CHD; N = 880, OR = 2.34, 95% CI 1.33 to 4.12, I2= 83.1%), and peripheral vascular disease (N = 172, OR = 2.77, 95% CI 1.50 to 5.13, I2= 0.0%) increased the risk for iNPH, while overweight was a possible factor (N = 225, OR = 2.01, 95% CI 1.34 to 3.04, I2= 0.0%) based on the sensitivity analysis. Smoking and alcohol consumption were not associated with iNPH. Conclusions Our study suggested that hypertension, DM, CHD, peripheral vascular disease, and overweight were associated with iNPH. These factors might be involved in the pathophysiological mechanisms promoting iNPH. These findings require further investigation in future studies. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, CRD42022383004.
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Affiliation(s)
- Hanlin Cai
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Feng Yang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Hui Gao
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Keru Huang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Linyuan Qin
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Ruihan Wang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Yi Liu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Liangxue Zhou
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Zilong Hao
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Dong Zhou
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Qin Chen
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
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Pu J, Zhao YL, Gu YX, Hang CH, You YP, Wang MD, Qu Y, Lu H, Wang S. Chinese expert consensus on the management of aneurysmal subarachnoid hemorrhage-related hydrocephalus. Chin Neurosurg J 2023; 9:7. [PMID: 36935494 PMCID: PMC10026498 DOI: 10.1186/s41016-022-00314-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 12/25/2022] [Indexed: 03/21/2023] Open
Affiliation(s)
- Jun Pu
- Department of Neurosurgery, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yuan-Li Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu-Xiang Gu
- Huashan Hospital, Affiliated to Fudan University, Shanghai, China
| | - Chun-Hua Hang
- Nanjing Drum Tower Hospital, Nanjing University Medical College, Nanjing, China
| | - Yong-Ping You
- Department of Interventional Neuroradiology, Jiangsu Province Hospital, Nanjing, China
| | - Mao-de Wang
- First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yan Qu
- Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Hua Lu
- Department of Interventional Neuroradiology, Jiangsu Province Hospital, Nanjing, China.
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Pedersen SH, Prein TH, Ammar A, Grotenhuis A, Hamilton MG, Hansen TS, Kehler U, Rekate H, Thomale UW, Juhler M. How to define CSF overdrainage: a systematic literature review. Acta Neurochir (Wien) 2023; 165:429-441. [PMID: 36639536 DOI: 10.1007/s00701-022-05469-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/20/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE Overdrainage (OD) is one of the most frequent complications related to drainage of the cerebrospinal fluid (CSF). It is mostly associated with valve-bearing shunt systems but should probably be considered as a risk factor in any type of CSF diversion procedure. There is extreme variation in the reported incidence of OD due to the lack of consensus on defining criteria and an unclear perception of the pathophysiology. Hence, OD is probably underreported and underestimated. The objective of this paper was to establish a definition of OD, based on a systematic review of the literature. METHODS A systematic search was conducted in MEDLNE and EMBASE. Studies providing a definition or a description of diagnostic findings related to OD in ventriculoperitoneal shunt treated hydrocephalus were included. Non-English titles, abstracts and manuscripts were excluded. Extracted descriptions were graded into five groups (class I-V studies) based on how precise the terminology used to describe OD was. Class I studies were included for further analysis and characteristics of OD were extracted. The quality of included descriptions was assessed by a clinical expert panel. RESULTS A total of 1309 studies were screened, 190 were graded into groups, and 22, which provided specific definitions or descriptions of OD, were graded as class I studies. We extracted 32 different characteristics consistent with OD (e.g., clinical symptoms, radiological signs, and syndromes). CONCLUSION There was an overall agreement that CSF overdrainage following implantation of a ventriculoperitoneal shunt in a mixed pediatric and adult population is characterized as a persistent condition with clinically manifestations as postural dependent headache, nausea, and vomiting and/or radiological signs of slim ventricles and/or subdural collections.
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Affiliation(s)
| | - Tobias Hannibal Prein
- Centre for Orthopaedic Research and Innovation, Slagelse Hospital, Slagelse, Denmark
| | - Ahmed Ammar
- Department of Neurosurgery, King Fahd University Hospital, Al Khobar, Saudi Arabia
| | | | - Mark G Hamilton
- Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Calgary, Canada
| | | | - Uwe Kehler
- Department of Neurosurgery, Asklepios Klinik Altona, Hamburg, Germany
| | - Harold Rekate
- The Donald and Barbara Zucker Hofstra Northwell School of Medicine, Hempstead, New York, USA
| | | | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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11
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Golubovsky JL, Liao J, Hogue O, Pucci F, Rammo R, Lipman J, Aminian A, Nagel SJ. Complications Associated With Ventriculoperitoneal Shunt Surgery for Normal Pressure Hydrocephalus Using Stereotactic Navigation and Abdominal Laparoscopy: A Single-Institution Case Series. Oper Neurosurg (Hagerstown) 2022; 23:188-193. [PMID: 35972080 DOI: 10.1227/ons.0000000000000290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 03/24/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Normal pressure hydrocephalus (NPH) is characterized by cerebral ventriculomegaly and the triad of magnetic gait, urinary incontinence, and cognitive impairment. Treatment includes ventriculoperitoneal (VP) shunt surgery. OBJECTIVE To evaluate complication rates in a cohort of patients undergoing VP shunt surgery with stereotactic proximal catheter navigation and laparoscopic distal catheter placement. METHODS This study was a retrospective consecutive cohort analysis of 117 patients with NPH undergoing VP shunt placement using both stereotactic navigation and laparoscopy from 2015 to 2020. Patients with obstructive hydrocephalus and those with central nervous system infection, intraventricular hemorrhage, Ommaya reservoirs, or undergoing shunt revision at initial encounter were excluded. Variables included demographics and comorbidities, NPH symptoms, operative details, radiographic outcomes, and rates of complications, readmissions, and reoperations within 1, 3, and 12 months. Impact of demographics and comorbidities on complication rates was assessed using Fisher exact tests. RESULTS Zero patients required reoperation within 30 days. One intracranial hemorrhage was detected on immediate postoperative head computed tomography. Four patients ultimately required revision: 2 for catheter repositioning to alleviate abdominal pain, 1 ligation for a colectomy, and 1 removal for shunt infection. Patients with cardiac or other neurological comorbidities had higher rates of readmission and complications. Systemic complications totaled 12% in the first 30 days. CONCLUSION The combination of intraoperative stereotactic navigation and laparoscopic assistance leads to low rates of serious complications and reoperations for VP shunt implantation in patients with NPH. These changes to surgical technique are easy to implement and may reduce the risk for this common operation.
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Affiliation(s)
- Joshua L Golubovsky
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Education Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - James Liao
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Olivia Hogue
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francesco Pucci
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Richard Rammo
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jeremy Lipman
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ali Aminian
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sean J Nagel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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12
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Phillips HW, Maniquis CA, Chen JS, Duby SL, Nagahama Y, Bergeron D, Ibrahim GM, Weil AG, Fallah A. Midline Brain Shift After Hemispheric Surgery: Natural History, Clinical Significance, and Association With Cerebrospinal Fluid Diversion. Oper Neurosurg (Hagerstown) 2022; 22:269-276. [PMID: 35315814 PMCID: PMC9514754 DOI: 10.1227/ons.0000000000000134] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hemispherectomy and its modern variants are effective surgical treatments for medically intractable unihemispheric epilepsy. Although some complications such as posthemispherectomy hydrocephalus are well documented, midline brain shift (MLBS) after hemispheric surgery has only been described anecdotally and never formally studied. OBJECTIVE To assess the natural history and clinical relevance of MLBS and determine whether cerebrospinal fluid (CSF) shunting of the ipsilateral surgical cavity exacerbates MLBS posthemispheric surgery. METHODS A retrospective review of consecutive pediatric patients who underwent hemispheric surgery for intractable epilepsy and at least 6 months of follow-up at UCLA between 1994 and 2018 was performed. Patients were grouped by MLBS severity, shunt placement, valve type, and valve opening pressure (VOP). MLBS was evaluated using the paired samples t-test and analysis of covariance adjusting for follow-up time and baseline postoperative MLBS. RESULTS Seventy patients were analyzed, of which 23 (33%) required CSF shunt placement in the ipsilateral surgical cavity for posthemispherectomy hydrocephalus. MLBS increased between first and last follow-up for nonshunted (5.3 ± 4.9-9.7 ± 6.6 mm, P < .001) and shunted (6.6 ± 3.5-16.3 ± 9.4 mm, P < .001) patients. MLBS progression was greater in shunted patients (P = .001). Shunts with higher VOPs did not increase MLBS relative to nonshunted patients (P = .834), whereas MLBS increased with lower VOPs (P = .001). Severe MLBS was associated with debilitating headaches (P = .048). CONCLUSION Patients undergoing hemispheric surgery often develop postoperative MLBS, ie, exacerbated by CSF shunting of the ipsilateral surgical cavity, specifically when using lower VOP settings. MLBS exacerbation may be related to overshunting. Severe MLBS is associated with debilitating headaches.
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Affiliation(s)
- H. Westley Phillips
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA;
| | - Cassia A.B. Maniquis
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA;
| | - Jia-Shu Chen
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA;
| | - Shannon L. Duby
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA;
| | - Yasunori Nagahama
- Department of Neurosurgery, Rutgers—Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA;
| | - David Bergeron
- Division of Neurosurgery, University of Montreal, Montreal, Canada;
| | - George M. Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada;
| | - Alexander G. Weil
- Division of Neurosurgery, Ste. Justine Hospital, University of Montreal, Montreal, Canada;
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA;
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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13
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Huo CW, King J, Goldschlager T, Dixon B, Chen Zhao Y, Uren B, Wang YY. The effects of cerebrospinal fluid (CSF) diversion on post-operative CSF leak following extended endoscopic anterior skull base surgery. J Clin Neurosci 2022; 98:194-202. [PMID: 35189544 DOI: 10.1016/j.jocn.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/18/2022] [Accepted: 02/04/2022] [Indexed: 11/24/2022]
Abstract
There is a paucity of high quality evidence regarding the routine placement of lumbar drain (LD) in reducing post-operative (op) cerebrospinal fluid (CSF) leak after extended endoscopic trans-sphenoidal resection of anterior skull base lesions. In this study, we sought to compare the incidence of post-op CSF leak between patients with upfront LD insertion and those without it. This was a prospective randomized controlled trial conducted over a period of 5 years with patients undergoing extended endoscopic trans-sphenoidal surgery randomly assigned to either LD insertion at the time of surgery, or no LD placement. Thirty-eight patients with anterior skull base tumors were accrued from three tertiary hospitals of Melbourne. Post-op leak was confirmed by β2-transferrin-positive rhinorrhea, and/or worsening pneumocephalus on brain imaging. Skull base defect size and pedicled nasoseptal flap viability were assessed on post-op CT and MRI, respectively. There was no significant difference in post-op CSF leak incidence between the two subgroups (12.50% in LD arm vs. 9.10% in no LD arm). Patients with LD insertion however, demonstrated substantially raised complication rates, longer hospital lengths of stay and lower subjective quality of life measures at 12 months compared with those without LD. In conclusion, routine placement of LD at the time of surgery for extended anterior skull base trans-nasal approach did not reduce the risk of post-op CSF leak. Discretion is warranted when using LD as an adjunct due to its associated morbidities, prolonged hospital stay and adverse effect on patients' subjective outcome measures.
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Affiliation(s)
- Cecilia W Huo
- Department of Neurosurgery, St Vincent's Hospital Melbourne, VIC 3065, Australia.
| | - James King
- Department of Neurosurgery, The Royal Melbourne Hospital, VIC 3050, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Medical Centre, VIC 3168, Australia
| | - Benjamin Dixon
- The Head and Neck/ENT Unit, St Vincent's Hospital Melbourne, VIC 3065, Australia
| | - Yi Chen Zhao
- The Head and Neck/ENT Unit, The Royal Melbourne Hospital, VIC 3050, Australia
| | - Brent Uren
- The Head and Neck/ENT Unit, Monash Medical Centre, VIC 3168, Australia
| | - Yi Yuen Wang
- Department of Neurosurgery, St Vincent's Hospital Melbourne, VIC 3065, Australia; Department of Surgery, The University of Melbourne, VIC Australia
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14
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Proposal for a Normal Pressure Hydrocephalus Syndrome Center of Excellence. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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15
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Cogswell PM, Murphy MC, Senjem ML, Botha H, Gunter JL, Elder BD, Graff-Radford J, Jones DT, Cutsforth-Gregory JK, Schwarz CG, Meyer FB, Huston J, Jack CR. Changes in Ventricular and Cortical Volumes following Shunt Placement in Patients with Idiopathic Normal Pressure Hydrocephalus. AJNR Am J Neuroradiol 2021; 42:2165-2171. [PMID: 34674997 DOI: 10.3174/ajnr.a7323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 08/18/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE While changes in ventricular and extraventricular CSF spaces have been studied following shunt placement in patients with idiopathic normal pressure hydrocephalus, regional changes in cortical volumes have not. These changes are important to better inform disease pathophysiology and evaluation for copathology. The purpose of this work is to investigate changes in ventricular and cortical volumes in patients with idiopathic normal pressure hydrocephalus following ventriculoperitoneal shunt placement. MATERIALS AND METHODS This is a retrospective cohort study of patients with idiopathic normal pressure hydrocephalus who underwent 3D T1-weighted MR imaging before and after ventriculoperitoneal shunt placement. Images were analyzed using tensor-based morphometry with symmetric normalization to determine the percentage change in ventricular and regional cortical volumes. Ventricular volume changes were assessed using the Wilcoxon signed rank test, and cortical volume changes, using a linear mixed-effects model (P < .05). RESULTS The study included 22 patients (5 women/17 men; mean age, 73 [SD, 6] years). Ventricular volume decreased after shunt placement with a mean change of -15.4% (P < .001). Measured cortical volume across all participants and cortical ROIs showed a mean percentage increase of 1.4% (P < .001). ROIs near the vertex showed the greatest percentage increase in volume after shunt placement, with smaller decreases in volume in the medial temporal lobes. CONCLUSIONS Overall, cortical volumes mildly increased after shunt placement in patients with idiopathic normal pressure hydrocephalus with the greatest increases in regions near the vertex, indicating postshunt decompression of the cortex and sulci. Ventricular volumes showed an expected decrease after shunt placement.
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Affiliation(s)
- P M Cogswell
- From the Departments of Radiology (P.M.C., M.C.M., J.L.G., C.G.S., J.H., C.R.J.)
| | - M C Murphy
- From the Departments of Radiology (P.M.C., M.C.M., J.L.G., C.G.S., J.H., C.R.J.)
| | | | - H Botha
- Neurology (H.B., J.G.-R., D.T.J., J.K.C.-G.)
| | - J L Gunter
- From the Departments of Radiology (P.M.C., M.C.M., J.L.G., C.G.S., J.H., C.R.J.)
| | - B D Elder
- Neurosurgery (B.D.E., F.B.M.)
- Biomedical Engineering (B.D.E.), Mayo Clinic, Rochester, Minnesota
| | | | - D T Jones
- Neurology (H.B., J.G.-R., D.T.J., J.K.C.-G.)
| | | | - C G Schwarz
- From the Departments of Radiology (P.M.C., M.C.M., J.L.G., C.G.S., J.H., C.R.J.)
| | | | - J Huston
- From the Departments of Radiology (P.M.C., M.C.M., J.L.G., C.G.S., J.H., C.R.J.)
| | - C R Jack
- From the Departments of Radiology (P.M.C., M.C.M., J.L.G., C.G.S., J.H., C.R.J.)
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16
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Sergej R, Leonie G, Holger A, Pawel G, Ullrich M, Johannes L. The role of shuntography in diagnosis of mechanic complications after implantation of ventriculoperitoneal shunts in patients with idiopathic normal pressure hydrocephalus: a retrospective clinical evaluation. Neuroradiology 2021; 64:745-752. [PMID: 34825966 PMCID: PMC8907103 DOI: 10.1007/s00234-021-02834-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/11/2021] [Indexed: 11/26/2022]
Abstract
Background Mechanical obstruction of ventriculoperitoneal shunt (VPS) during the first year after shunt implantation is a common complication and is widely described in the literature. In this paper, we evaluated the suitability of the shuntography for the diagnosis of mechanical complications of the VPS in patients with idiopathic normal pressure hydrocephalus (iNPH). Methods We retrospectively identified 49 patients with pathologic shuntography over of a period of 20 years in our hospital. The percentage of procedure-associated complications was determined. Results Ninety-eight percent (n = 48) of the patients who underwent shuntography showed clinical and radiographic signs of underdrainage prior to examination. Shuntography revealed mechanical complications of the VP shunt in 37% (n = 18) as a cause of clinical deterioration and following revision operation. During shuntography, mechanical obstruction was discovered in 78% (n = 14) and disconnection of shunt components in 22% (n = 4). In the obstruction group, in 50% (n = 7) the closure was detected in the ventricular catheter, in 29% (n = 4) in the distal catheter of the VPS, and in 21% (n = 3) in both sides of the VPS. In the case of an inconspicuous shuntography (63%, n = 31), the patients received symptomatic therapy (32%, n = 10) or re-adjustment of the valve setting (68%, n = 21). Fifty-seven percent of the patients who underwent surgical treatment improved clinically by at least one point according to the Kiefer score. Conclusion Shuntography can produce valuable clinical information uncovering mechanic complications after implantation VPS in patients with idiopathic normal-pressure hydrocephalus. Patients with mechanical complications of their VPS needed revision surgery and showed clinical benefit after treatment.
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Affiliation(s)
- Rot Sergej
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.
| | - Goelz Leonie
- Institute of Radiology and Neuroradiology, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Arndt Holger
- Institute of Radiology and Neuroradiology, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Gutowski Pawel
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.,Department of Neurosurgery, Brodno Masovian Hospital, Warsaw Postgraduate Medical Centre, Warsaw, Poland
| | - Meier Ullrich
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Lemcke Johannes
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
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17
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Lodhia J, Rashid SM, Msemo A, Philemon R, Sadiq A, Chilonga K, Msuya D. Bilateral Subdural Hematoma following Ventriculoperitoneal Shunt Insertion in a Ten-month Old Tanzanian Female with Congenital Hydrocephalus: An Uncommon Presentation. East Afr Health Res J 2021; 5:17-19. [PMID: 34308240 PMCID: PMC8291209 DOI: 10.24248/eahrj.v5i1.646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/23/2021] [Indexed: 11/20/2022] Open
Abstract
There is an unmet need for the treatment of hydrocephalus in Tanzania. Thousands of newborns each year in the region are affected by this condition and access to care remains a challenge. While treatment options like cerebrospinal fluid diversion through ventriculo-peritoneal shunting are within the skill set of general surgeons, the potential complications represent an additional challenge. We present a 10-month-old Tanzanian female who developed bilateral-subdural hematomas after insertion of a ventriculoperitoneal shunt.
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Affiliation(s)
- Jay Lodhia
- Department of General Surgery, Kilimanjaro Christian Medical Center, Moshi-Tanzania
| | | | - Abdallah Msemo
- Department of General Surgery, Kilimanjaro Christian Medical Center, Moshi-Tanzania
| | - Rune Philemon
- Kilimanjaro Christian Medical University College, Moshi-Tanzania.,Department of Pediatrics and Child Health, Kilimanjaro Christian Medical Center, Moshi-Tanzania
| | - Adnan Sadiq
- Kilimanjaro Christian Medical University College, Moshi-Tanzania.,Department of Radiology, Kilimanjaro Christian Medical Center, Moshi-Tanzania
| | - Kondo Chilonga
- Department of General Surgery, Kilimanjaro Christian Medical Center, Moshi-Tanzania.,Kilimanjaro Christian Medical University College, Moshi-Tanzania
| | - David Msuya
- Department of General Surgery, Kilimanjaro Christian Medical Center, Moshi-Tanzania.,Kilimanjaro Christian Medical University College, Moshi-Tanzania
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18
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Yerneni K, Karras CL, Larkin CJ, Weiss H, Hopkins B, Kesavabhotla K, Potts MB, Tate MC, Bloch O. Lumboperitoneal shunts for the treatment of idiopathic normal pressure hydrocephalus. J Clin Neurosci 2021; 86:1-5. [PMID: 33775310 DOI: 10.1016/j.jocn.2020.12.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 11/02/2020] [Accepted: 12/25/2020] [Indexed: 11/19/2022]
Abstract
The standard of care for idiopathic normal pressure hydrocephalus (iNPH) is placement of a ventriculoperitoneal (VP) shunt. However, VP shunts require intracranial intervention and are associated with notable postoperative complications, with some groups reporting complication rates for VP shunts ranging from 17 to 33%, along with failure rates up to 17.7%. Lumboperitoneal (LP) shunts are an alternative for cerebrospinal fluid diversion that do not require intracranial surgery, thus providing utility in patients where intracranial surgery is not possible or preferred. Here we retrospectively reviewed our 25 patients with LP horizontal-vertical (LP-HV) shunts placement for initial treatment for iNPH from 2014 to 2019. All patients had preoperative gait dysfunction, 16 (64%) had urinary incontinence, and 21 (84%) exhibited cognitive insufficiency. Two weeks post-shunt placement, 23/25 (92%) patients demonstrated improvement in gait, 11/16 (68%) had improvement in incontinence, and 14/21 (66%) had improvement cognitive insufficiency. At six months or greater follow up 13/20 (65%) had improvement in gait, 7/15 (47%) showed improvement in incontinence, and 11/15 (73%) demonstrated improvement in cognitive function. Six patients (24%) required at least one revision of the LP shunt. Shunt malfunctions resulted from CSF leak in one patient, shunt catheter migration in two patients, peritoneal catheter pain in one patient, and clinical symptoms for overdrainage in two patients. Thus, we demonstrate that LP-HV shunt placement is safe and efficacious alternative to VP shunting for iNPH, resulting in notable symptomatic improvement and low risk of overdrainage, and may be considered for patients where cranial approaches should be avoided.
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Affiliation(s)
- Ketan Yerneni
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States
| | - Constantine L Karras
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States.
| | - Collin J Larkin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States; Department of Neurological Surgery, University of California at Davis, Davis, CA 95817, United States
| | - Hannah Weiss
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States; Department of Neurological Surgery, University of California at Davis, Davis, CA 95817, United States
| | - Benjamin Hopkins
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States
| | - Kartik Kesavabhotla
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States
| | - Matthew B Potts
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States
| | - Matthew C Tate
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States
| | - Orin Bloch
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States; Department of Neurological Surgery, University of California at Davis, Davis, CA 95817, United States
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19
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Nouri A, Gondar R, Schaller K, Meling T. Chronic Subdural Hematoma (cSDH): A review of the current state of the art. BRAIN AND SPINE 2021; 1:100300. [PMID: 36247395 PMCID: PMC9560707 DOI: 10.1016/j.bas.2021.100300] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Introduction Incidence of Chronic Subdural Hematoma (cSDH) is rising worldwide, partly due to an aging population, but also due to increased use of antithrombotic medication. Many recent studies have emerged to address current cSDH management strategies. Research question What is the state of the art of cSDH management. Material and methods Review. Results Head trauma, antithrombotic use and craniocerebral disproportion increase the risk of cSDH development. Most patients present with disorientation, GCS 13–15, and symptoms arising from cortical irritation and increased intracranial pressure. cSDH occurs bilaterally in 9–22%. CT allows assessment of cerebral compression (herniation, hematoma thickness, ventricle collapse, midline shift), hematoma age and presence of membranes, factors that ultimately determine treatment urgency and surgical approach. Recurrence remains the principle complication (9–33%), occurring more commonly with older age and bilateral cSDHs. Discussion and conclusion While incompletely understood, it is generally believed that injury in the dural cell layer results in bleeding from bridging veins, resulting in a hematoma formation, with or without a preceding hygroma, in a potential space approximating the junction between the dura and arachnoid. Neovascularization and leaking from the outer membrane are thought to propagate this process. Evidence that MMA embolization may reduce recurrence rates is a potentially exciting new treatment option, but also supports the theory that the MMA is implicated in the cSDH pathophysiology. The use of steroids remains a controversial topic without clear treatment guidelines. cSDH represents a common neurosurgical problem with burr-hole treatment remaining the gold standard, often in conjunction with subgaleal drains. MMA embolization to stop recurrence may represent an important evolution in understanding the pathophysiology of cSDH and improving treatment. Incidence of cSDH is rising, partly due to the aging population and increased antithrombotic use. cSDH occurs bilaterally in 9–22% of cases. Recurrence remains the principle complication and has been estimated at 9–33%. Risk factors for recurrence include old age and bilateral cSDHs. MMA embolization may reduce recurrence, but its efficacy and target population remain unclear.
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20
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Funnell JP, D’Antona L, Craven CL, Thorne L, Watkins LD, Toma AK. Ultra-low-pressure hydrocephalic state in NPH: benefits of therapeutic siphoning with adjustable antigravity valves. Acta Neurochir (Wien) 2020; 162:2967-2974. [PMID: 32989519 DOI: 10.1007/s00701-020-04596-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/24/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Idiopathic normal-pressure hydrocephalus (NPH) is a condition of the elderly treated by ventriculoperitoneal shunt (VP) insertion. A subset of NPH patients respond only temporarily to shunt insertion despite low valve opening pressure. This study aims to describe our experience of patients who benefit from further CSF drainage by adding adjustable antigravity valves and draining CSF at ultra-low pressure. METHODS Single-centre retrospective case series of patients undergoing shunt valve revision from an adjustable differential pressure valve with fixed antigravity unit to a system incorporating an adjustable gravitational valve (Miethke proSA). Patients were screened from a database of NPH patients undergoing CSF diversion over 10 consecutive years (April 2008-April 2018). Clinical records were retrospectively reviewed for interventions and clinical outcomes. RESULTS Nineteen (10F:9M) patients underwent elective VP shunt revision to a system incorporating an adjustable gravitational valve. Mean age 77.1 ± 7.1 years (mean ± SD). Eleven patients (58%) showed significant improvement in walking speed following shunt revision. Fourteen patients/carers (74%) reported subjective improvements in symptoms following shunt revision. CONCLUSIONS Patients presenting symptoms relapse following VP shunting may represent a group of patients with ultra-low-pressure hydrocephalus, for whom further CSF drainage may lead to an improvement in symptoms. These cases may benefit from shunt revision with an adjustable gravitational valve, adjustment of which can lead to controlled siphoning of CSF and drain CSF despite ultra-low CSF pressure.
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21
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Nadel JL, Wilkinson DA, Linzey JR, Maher CO, Kotagal V, Heth JA. Thirty-Day Hospital Readmission and Surgical Complication Rates for Shunting in Normal Pressure Hydrocephalus: A Large National Database Analysis. Neurosurgery 2020; 86:843-850. [PMID: 31420654 DOI: 10.1093/neuros/nyz299] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 05/09/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Research on age-related complications secondary to shunts in normal pressure hydrocephalus (NPH) is primarily limited to single-center studies and small cohorts. OBJECTIVE To determine the rates of hospital readmission and surgical complications, and factors that predict them, following shunt surgery for NPH in a large healthcare network. METHODS Surgical procedures, complications, and readmissions for adults undergoing ventricular shunting for NPH were determined using de-identified claims from a privately insured United States healthcare network in years 2007-2014. Univariate and multivariate statistics were used to determine factors that predict poor surgical outcomes. The primary outcome variable was surgical complications or readmissions (composite variable for any major perioperative complication or 30-d readmission). RESULTS The 30-d readmission rate for 974 patients with NPH who underwent ventricular shunting was 7.29%; the most common reasons for readmission were shunt-related complications, infection, hemorrhage, altered mental status, and cardiopulmonary and musculoskeletal problems. The perioperative complication rate was 21.15%, including intraparenchymal hemorrhage (5.85%) and extra-axial (subdural or epidural) hematoma (5.54%). The overall rate of having a surgical complication or 30-d readmission was 25.15%. Age did not predict surgical complication or 30-d readmission. Preoperative comorbidities independently associated with poor outcome were myocardial infarction within 1 yr (OR = 3.984, 95% CI = 1.105-14.368); existing cerebrovascular disease (odds ratio [OR] = 2.206, 95% CI = 1.544-3.152); and moderate/severe renal disease (OR = 2.000, 95% CI = 1.155-3.464). CONCLUSION The rate of complications or readmission within 30 d of ventricular shunting for NPH is 25.15%. Preoperative comorbidities of myocardial infarction within 1 yr, cerebrovascular disease, and moderate/severe renal disease are independent risk factors for poor outcome.
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Affiliation(s)
- Jeffrey L Nadel
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan
| | | | - Joseph R Linzey
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan
| | - Cormac O Maher
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Vikas Kotagal
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Jason A Heth
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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22
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Feletti A, d'Avella D, Wikkelsø C, Klinge P, Hellström P, Tans J, Kiefer M, Meier U, Lemcke J, Paternò V, Stieglitz L, Sames M, Saur K, Kordás M, Vitanovic D, Gabarrós A, Llarga F, Triffaux M, Tyberghien A, Juhler M, Hasselbalch S, Cesarini K, Laurell K. Ventriculoperitoneal Shunt Complications in the European Idiopathic Normal Pressure Hydrocephalus Multicenter Study. Oper Neurosurg (Hagerstown) 2020; 17:97-102. [PMID: 30169650 DOI: 10.1093/ons/opy232] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 07/28/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ventriculoperitoneal shunt (VP-shunt) is the standard of treatment for idiopathic normal pressure hydrocephalus (iNPH). However, a thorough investigation of VP-shunt complications in this population is lacking. OBJECTIVE To present the analysis and the rates of complications progressively occurring during the first year after shunt surgery in the patients with iNPH included in the European multicenter (EU-iNPH) study. METHODS Patients (n = 142) were prospectively included in the EU-iNPH study by 13 institutions. All patients received a programmable VP-shunt. One hundred fifteen patients completed the 12-mo follow-up. Reexaminations were performed 1, 3, and 12 mo after surgery. Data regarding symptomatic over- or underdrainage, infections, malposition, subdural collections, and shunt surgery were collected and analyzed. RESULTS Thirty patients (26%) experienced symptoms due to shunt underdrainage. Symptomatic overdrainage was reported in 10 (9%). Shunt adjustments were made in 43 (37%). Shunt malposition was recognized as the primary cause of shunt malfunction in 8 (7%), while only 1 infection (0.9%) occurred. Subdural hematoma was diagnosed in 7 (6%) and was treated by increasing the opening pressure of the valve in 5 patients. Hygroma was diagnosed in 10 (9%), requiring surgery in 1 patient. Overall, 17 patients (15%) underwent 19 shunt surgeries. CONCLUSION The advances in valve technology, a careful opening pressure setting, and rigorous follow-up allow a significant reduction of complications, which can be usually managed nonsurgically within the first 3 to 6 mo.
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Affiliation(s)
- Alberto Feletti
- Department of Neurosciences, Unit of Neurosurgery, NOCSAE Modena Hospital, Modena, Italy
| | - Domenico d'Avella
- Department of Neurosciences, Academic Neurosurgery, University of Padova, Padova, Italy
| | - Carsten Wikkelsø
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Petra Klinge
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Per Hellström
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jos Tans
- Department of Neurology, Medical Centre Haaglanden, The Hague, The Netherlands
| | - Michael Kiefer
- Department of Neurosurgery, Saarland University, Homburg-Saar, Germany
| | - Ulrich Meier
- Department of Neurosurgery. Akademisches Lehrkrankenhaus der Freien Universität Berlin. Krankenhaus Berlin-Marzahn, Berlin, Germany
| | - Johannes Lemcke
- Department of Neurosurgery. Akademisches Lehrkrankenhaus der Freien Universität Berlin. Krankenhaus Berlin-Marzahn, Berlin, Germany
| | - Vincenzo Paternò
- Department of Neurosurgery, International Neuroscience Institute Hannover, Hannover, Germany
| | - Lennart Stieglitz
- Department of Neurosurgery, International Neuroscience Institute Hannover, Hannover, Germany
| | - Martin Sames
- Department of Neurosurgery, Masaryk Hospital, Usti nad Labem, The Czech Republic
| | - Karel Saur
- Department of Neurosurgery, Masaryk Hospital, Usti nad Labem, The Czech Republic
| | | | | | | | | | - Michael Triffaux
- Service de Neurochirurgie. Clinique au Jardin Botanique 32, Brussels, Belgium
| | - Alain Tyberghien
- Service de Neurochirurgie. Clinique au Jardin Botanique 32, Brussels, Belgium
| | - Marianne Juhler
- Neurokirurgisk Klinik NK 2092, Memory Disorders Research Unit, The Neuroscience Center, N6702, Rigshospitalet, Copenhagen, Denmark
| | - Stehen Hasselbalch
- Neurokirurgisk Klinik NK 2092, Memory Disorders Research Unit, The Neuroscience Center, N6702, Rigshospitalet, Copenhagen, Denmark
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Arnts H, van Erp WS, Sanz LRD, Lavrijsen JCM, Schuurman R, Laureys S, Vandertop WP, van den Munckhof P. The Dilemma of Hydrocephalus in Prolonged Disorders of Consciousness. J Neurotrauma 2020; 37:2150-2156. [PMID: 32484029 DOI: 10.1089/neu.2020.7129] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Prolonged disorders of consciousness (DOC) are considered to be among the most severe outcomes after acquired brain injury. Medical care for these patients is mainly focused on minimizing complications, given that treatment options for patients with unresponsive wakefulness or minimal consciousness remain scarce. The complication rate in patients with DOC is high, both in the acute hospital setting, as in the rehabilitation or long-term care phase. Hydrocephalus is one of these well-known complications and usually develops quickly after acute changes in cerebrospinal fluid (CSF) circulation after different types of brain damage. However, hydrocephalus may also develop with a significant delay, weeks, or even months after the initial injury, reducing the potential for natural recovery of consciousness. In this phase, hydrocephalus is likely to be missed in DOC patients, given that their limited behavioral responsiveness camouflages the classic signs of increased intracranial pressure or secondary normal-pressure hydrocephalus. Moreover, the development of late-onset hydrocephalus may exceed the period of regular outpatient follow-up. Several controversies remain about the diagnosis of clinical hydrocephalus in patients with ventricular enlargement after severe brain injury. In this article, we discuss both the difficulties in diagnosis and dilemmas in the treatment of CSF disorders in patients with prolonged DOC and review evidence from the literature to advance an active surveillance protocol for the detection of this late, but treatable, complication. Moreover, we advocate a low threshold for CSF diversion when hydrocephalus is suspected, even months or years after brain injury.
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Affiliation(s)
- Hisse Arnts
- Department of Neurosurgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Willemijn S van Erp
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands.,GIGA Consciousness, University of Liège, Liège, Belgium; Coma Science Group, University Hospital of Liège, Liège, Belgium
| | - Leandro R D Sanz
- GIGA Consciousness, University of Liège, Liège, Belgium; Coma Science Group, University Hospital of Liège, Liège, Belgium
| | - Jan C M Lavrijsen
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Rick Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Steven Laureys
- GIGA Consciousness, University of Liège, Liège, Belgium; Coma Science Group, University Hospital of Liège, Liège, Belgium
| | - William P Vandertop
- Department of Neurosurgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
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24
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Gasslander J, Sundström N, Eklund A, Koskinen LOD, Malm J. Risk factors for developing subdural hematoma: a registry-based study in 1457 patients with shunted idiopathic normal pressure hydrocephalus. J Neurosurg 2020; 134:668-677. [PMID: 31923893 DOI: 10.3171/2019.10.jns191223] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 10/29/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Subdural hematomas and hygromas (SDHs) are common complications in idiopathic normal pressure hydrocephalus (iNPH) patients with shunts. In this registry-based study, patients with shunted iNPH were screened nationwide to identify perioperative variables that may increase the risk of SDH. METHODS The Swedish Hydrocephalus Quality Registry was reviewed for iNPH patients who had undergone shunt surgery in Sweden in 2004-2014. Potential risk factors for SDH were recorded preoperatively and 3 months after surgery. Drug prescriptions were identified from a national pharmacy database. Patients who developed SDHs were compared with those without SDHs. RESULTS The study population consisted of 1457 patients, 152 (10.4%) of whom developed an SDH. Men developed an SDH more often than women (OR 2.084, 95% CI 1.421-3.058, p < 0.001). Patients on platelet aggregation inhibitors developed an SDH more often than those who were not (OR 1.733, 95% CI 1.236-2.431, p = 0.001). At surgery, shunt opening pressures had been set 5.9 mm H2O lower in the SDH group than in the no-SDH group (109.6 ± 24.1 vs 115.5 ± 25.4 mm H2O, respectively, p = 0.009). Antisiphoning devices (ASDs) were used in 892 patients but did not prevent SDH. Mean opening pressures at surgery and the follow-up were lower with shunts with an ASD, without causing more SDHs. No other differences were seen between the groups. CONCLUSIONS iNPH patients in this study were diagnosed and operated on in routine practice; thus, the results represent everyday care. Male sex, antiplatelet medication, and a lower opening pressure at surgery were risk factors for SDH. Physical status and comorbidity were not. ASD did not prevent SDH, but a shunt with an ASD allowed a lower opening pressure without causing more SDHs.
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Affiliation(s)
- Johan Gasslander
- 1Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå
- 2Departments of Cardiology and Health, Medicine and Caring Services, Linkoping University, Vrinnevi General Hospital Norrköping; and
| | - Nina Sundström
- 3Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Anders Eklund
- 3Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Lars-Owe D Koskinen
- 1Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå
| | - Jan Malm
- 1Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå
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25
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Haber MA, Abd-El-Barr M, Gormley W, Mukundan S, Sodickson AD, Potter CA. Neurosurgical complications: what the radiologist needs to know. Emerg Radiol 2019; 26:331-340. [PMID: 30761443 DOI: 10.1007/s10140-019-01672-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/08/2019] [Indexed: 10/27/2022]
Abstract
Visits to the emergency department by patients who have recently undergone neurosurgery are a common occurrence, and these patients frequently receive emergent cross-sectional head imaging in order to evaluate for complications. Different neurosurgical approaches may have typical postoperative imaging findings that can be confused with pathology. Furthermore, particular abnormal postoperative imaging findings may signal an evolving complication. It is essential for the radiologist to understand common neurosurgical procedures and their potential complications in order to provide proper diagnostic evaluation of the postoperative neurosurgical patient. The purpose of this review is to assist radiologists in the evaluation of the postoperative neurosurgical patient and educate them on associated complications. Familiarity with common neurosurgical techniques and postoperative complications will help radiologists make the correct diagnosis, communicate effectively with the neurosurgeon, and expedite patient care.
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Affiliation(s)
- Matthew A Haber
- Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, USA.
| | - Muhammad Abd-El-Barr
- Department of Neurosurgery, Duke University Medical Center, 40 Duke Medicine Circle, Durham, NC, 27710, USA
| | - William Gormley
- Harvard Medical School, Boston, MA, USA.,Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Srinivasan Mukundan
- Harvard Medical School, Boston, MA, USA.,Division of Neuroradiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Aaron D Sodickson
- Harvard Medical School, Boston, MA, USA.,Division of Emergency Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Christopher A Potter
- Harvard Medical School, Boston, MA, USA.,Division of Neuroradiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Division of Emergency Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
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27
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Berger A, Constantini S, Ram Z, Roth J. Acute subdural hematomas in shunted normal-pressure hydrocephalus patients - Management options and literature review: A case-based series. Surg Neurol Int 2019; 9:238. [PMID: 30595959 PMCID: PMC6287333 DOI: 10.4103/sni.sni_338_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/25/2018] [Indexed: 11/29/2022] Open
Abstract
Background: Ventriculoperitoneal shunting (VPS) is considered a risk factor for developing subdural hematomas (SDH). Treating cases of acute SDH (aSDH) in shunted normal-pressure hydrocephalus (NPH) patients can be challenging, and data in this field are scarce. We report our experience treating shunted NPH patients presenting with aSDH. Methods: Eight patients, aged 73 ± 6 years, with a history of VPS for NPH, hospitalized because of aSDH were included in this study. We retrospectively analyzed data regarding patients’ clinical and radiological presentation, hospitalization course, the use of antithrombotics, and response to different treatment regimens. Results: Four patients had pure aSDH, three had acute on chronic SDH, and one had subacute SDH. Patients presented with GCS 13–15 and various neurological signs, mainly confusion and unsteady gate. Two cases improved following resetting of their programmable shunt valve to its maximal pressure setting. Six cases improved after evacuation of the hematomas, five of them were operated a few days after initially resetting of the valve pressure. Three patients were discharged home, whereas five were referred to rehabilitation. Extended Glasgow Outcome Scale scores at discharge and during long-term follow-up were 5 and 7, respectively. Conclusions: Treatment of patients with VPS for NPH, presenting with aSDH, may differ according to the neurological status, imaging, and clinical course. Treatment options include restricting shunt function, hematoma evacuation, or both.
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Affiliation(s)
- Assaf Berger
- Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Shlomi Constantini
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Tel-Aviv University, Tel-Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Tel-Aviv University, Tel-Aviv, Israel
| | - Jonathan Roth
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Tel-Aviv University, Tel-Aviv, Israel
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28
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Paff M, Alexandru-Abrams D, Muhonen M, Loudon W. Ventriculoperitoneal shunt complications: A review. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2018. [DOI: 10.1016/j.inat.2018.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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29
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Wetzel C, Goertz L, Schulte AP, Goldbrunner R, Krischek B. Minimizing overdrainage with flow-regulated valves - Initial results of a prospective study on idiopathic normal pressure hydrocephalus. Clin Neurol Neurosurg 2018; 173:31-37. [PMID: 30071502 DOI: 10.1016/j.clineuro.2018.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/17/2018] [Accepted: 07/22/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Overdrainage and frequent reprogramming are common issues with programmable valves after ventriculoperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (iNPH). Flow-regulated valves may address these limitations, but data on their efficacy are sparse. We present our single-center experience with flow-regulated valves focusing on overdrainage and efficiency. PATIENTS AND METHODS Thirty-two patients with iNPH treated with the Integra® NPH Low Flow Valve were prospectively enrolled. Clinical evaluation was performed at baseline, postoperatively as well as 3 and 6 months after surgery. The outcome was assessed by employing the iNPH grading scale and the Mini Mental Status Examination (MMSE). Overdrainage was assessed clinically and radiologically by computed tomography. RESULTS The mean patient age was 71 years. All patients presented with gait disturbance, 29 had cognitive impairment and 25 had urinary incontinence. The mean duration of symptoms was 22.9 months. At 3-month follow-up, 25/31 patients (80.6%) improved on the total iNPH score by at least 5 points (p < 0.001). The mean MMSE score increased from 24.5 to 26.1 points (p = 0.013). After 6 months, the improvement rates of the iNPH (82.1%) and the MMSE scores (26.8 points) were stable. The rate of clinically significant overdrainage was 3.2%. One patient presented with subdural hygromas that necessitated evacuation. In the remaining patients, clinical and radiological signs of overdrainage were absent. CONCLUSION The use of the Integra® NPH Low Flow Valve leads to a good neurological outcome and has low overdrainage rates without the need for reprogramming. These results are encouraging and justify further investigation of this valve.
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Affiliation(s)
- Christian Wetzel
- Center for Neurosurgery, University Hospital of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Lukas Goertz
- Center for Neurosurgery, University Hospital of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
| | - André Pascal Schulte
- Orthopedic Spine Surgery, St. Franziskus-Hospital, Schönsteinstrasse 63, 50825 Cologne, Germany
| | - Roland Goldbrunner
- Center for Neurosurgery, University Hospital of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Boris Krischek
- Center for Neurosurgery, University Hospital of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
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30
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Risk factors and outcomes of cerebrospinal fluid overdrainage in HIV-negative patients with cryptococcal meningitis after the ventriculoperitoneal shunting procedure. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2018; 51:545-551. [DOI: 10.1016/j.jmii.2017.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 05/16/2017] [Accepted: 06/06/2017] [Indexed: 11/20/2022]
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31
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Wang W, Wang M, Li Z, Wang T, Da R. The intraocular pressure could not be used to determine the intracranial pressure in patients with hydrocephalus. Int J Neurosci 2018; 129:42-48. [PMID: 29883235 DOI: 10.1080/00207454.2018.1486832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
PURPOSE An accurate intracranial pressure (ICP) measurement is vital for patients with hydrocephalus. ICP is generally measured by lumbar puncture opening pressure, which is invasive and has potential adverse side effects. Intraocular pressure (IOP) was investigated to measure ICP indirectly; however, its accuracy was controversial. We conducted this retrospective study to investigate whether IOP can be used as a surrogate for ICP in hydrocephalus patients. METHODS We performed a retrospective study enrolled 50 cases, including 32 patients with normal pressure hydrocephalus (NPH) and 18 patients with high pressure hydrocephalus (HPH). The independent factors of ICP, the correlation between ICP and other factors, and diagnostic value of IOP and papilledema to predict ICP were analysed, respectively. RESULTS Patients with HPH were more likely suffered from visual deterioration (33.33% vs. 9.38%, p = .045) and papilledema (55.56% vs. 3.13%, p = .001). Multivariate analysis revealed that papilledema was a significant factor (OR =40.765, 95%CI 3.331-498.846, p = .004). Pearson's correlation analysis indicated that ICP did not correlate with any other factors. CONCLUSIONS IOP was not an independent factor of ICP in patients with hydrocephalus, and could not be used to determine IOP. Papilledema might be a significant factor of ICP in hydrocephalus sufferers. Compared with NPH patients, patients with HPH were more prone to develop papilledema.
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Affiliation(s)
- Wei Wang
- a Department of Neurosurgery , The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , People's Republic of China
| | - Maode Wang
- a Department of Neurosurgery , The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , People's Republic of China
| | - Zhijin Li
- a Department of Neurosurgery , The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , People's Republic of China
| | - Tuo Wang
- a Department of Neurosurgery , The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , People's Republic of China
| | - Rong Da
- b Department of Clinical Laboratory , The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , People's Republic of China
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Serarslan Y, Yilmaz A, Çakır M, Güzel E, Akakin A, Güzel A, Urfalı B, Aras M, Kaya ME, Yılmaz N. Use of programmable versus nonprogrammable shunts in the management of normal pressure hydrocephalus: A multicenter retrospective study with cost-benefit analysis in Turkey. Medicine (Baltimore) 2017; 96:e8185. [PMID: 28953678 PMCID: PMC5626321 DOI: 10.1097/md.0000000000008185] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Ventriculoperitoneal shunt systems that are used in the treatment of normal pressure hydrocephalus are often associated with drainage problems. Adjustable shunt systems can prevent or treat these problems, but they may be expensive. The aim of our study is to compare the complications and total cost of several shunt systems.Patients with normal pressure hydrocephalus who underwent ventriculoperitoneal shunting between 2011 and 2016 were included in the study. The study involves patient consent and the informed consent was given. Complications and the average cost per person were compared between patients with adjustable and nonadjustable shunts. Shunt prices, surgical complications, and revision costs were taken into account to calculate the average cost.Of the 110 patients who were evaluated, 80 had a nonadjustable shunt and 30 had an adjustable shunt. In the group with adjustable shunts, the rates of subdural effusion and hematoma were 19.73% and 3.29%, respectively. In the group with nonadjustable shunts, these rates were 22.75% and 13.75%, respectively. One patient in the adjustable group underwent surgery for subdural hematoma, while 8 patients in the nonadjustable group underwent the same surgery. Ten patients required surgical intervention for subdural effusion and existing shunt systems in these patients were replaced by an adjustable shunt system. When these additional costs were factored into the analysis, the difference in cost between the shunt systems was reduced from 600 United States dollars (USD) to 111 USD.When the complications and additional costs that arise during surgical treatment of normal pressure hydrocephalus were considered, the price difference between adjustable and nonadjustable shunt systems was estimated to be much lower.
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Affiliation(s)
| | - Atilla Yilmaz
- Neurosurgery Department, Mustafa Kemal University, Hatay
| | - Mürteza Çakır
- Neurosurgery Department, Ataturk University, Erzurum
| | - Ebru Güzel
- Radiology Department, Gaziantep Medical Park Hospital, Gaziantep
| | - Akin Akakin
- Neurosurgery Department, Bahcesehir University, Istanbul
| | - Aslan Güzel
- Neurosurgery Department, Gaziantep Medical Park Hospital, Bahcesehir University, Gaziantep
| | - Boran Urfalı
- Neurosurgery Department, Mustafa Kemal University, Hatay
| | - Mustafa Aras
- Neurosurgery Department, Mustafa Kemal University, Hatay
| | | | - Nebi Yılmaz
- Neurosurgery Department, Eryaman Hospital, Ankara, Turkey
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33
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D'Anza B, Tien D, Stokken JK, Recinos PF, Woodard TR, Sindwani R. Role of lumbar drains in contemporary endonasal skull base surgery: Meta-analysis and systematic review. Am J Rhinol Allergy 2017; 30:430-435. [PMID: 28124655 DOI: 10.2500/ajra.2016.30.4377] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Historically, lumbar drains (LD) have played a prominent role in endonasal skull base surgery. Over the past few decades, advancements in techniques have augmented our ability to successfully reconstruct complex skull base defects and often obviates the need for cerebrospinal fluid (CSF) diversion. Clarity on the appropriate use of LDs is needed. OBJECTIVE To examine the literature for the need for LDs in contemporary skull base reconstruction after resection of skull base tumors. METHODS A systematic literature review of English language articles by using PubMed and Ovid. Search terms included "lumbar drain," "CSF leak," and "endoscopic endonasal reconstruction." Articles were included when they pertained to adults, used current methods for reconstruction (i.e., multilayered repair or vascularized tissue), and addressed CSF leak rates secondary to endoscopic resection of skull base masses. All the studies discussed CSF leaks that resulted from traumatic-, idiopathic-, or sinus surgery-related iatrogenic causes were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. RESULTS A total of five articles met inclusion criteria. These comprised 376 endoscopic skull base tumor resection and reconstruction cases; 5.59% developed postoperative CSF leaks. A meta-analysis was conducted by incorporating three studies that met criteria based on testing for heterogeneity. The average odds ratio for postoperative CSF leak for patients who did not have an LD relative to patients who had an LD was 0.590 (95% confidence interval, 0.214-1.630). Given a p value of 0.30, the results demonstrated a lack of statistically significant improvement between patients who had an LD and patients who did not have an LD. Various details, such as the defect size and type of CSF leak, were not consistently reported among studies. CONCLUSIONS Available evidence for the use of LDs in skull base surgery is of poor quality. Analysis of the literature revealed heterogenous and varied reporting in the primary literature. Further studies that include randomized controlled trials are needed.
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Affiliation(s)
- Brian D'Anza
- Division of Rhinology, Allergy and Skull Base Surgery, Department of Otolaryngology, University Hospitals, Case Western Reserve University, Cleveland, Ohio, USA
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Israelsson H, Carlberg B, Wikkelsö C, Laurell K, Kahlon B, Leijon G, Eklund A, Malm J. Vascular risk factors in INPH: A prospective case-control study (the INPH-CRasH study). Neurology 2017; 88:577-585. [PMID: 28062721 DOI: 10.1212/wnl.0000000000003583] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 10/14/2016] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To assess the complete vascular risk factor (VRF) profile of idiopathic normal pressure hydrocephalus (INPH) using a large sample of representative patients with INPH and population-based controls to determine the extent to which vascular disease influences INPH pathophysiology. METHODS All patients with INPH who underwent shunting in Sweden in 2008-2010 were compared to age- and sex-matched population-based controls. Inclusion criteria were age 60-85 years and no dementia. The 10 most important VRFs and cerebrovascular and peripheral vascular disease were prospectively assessed using blood samples, clinical examinations, and standardized questionnaires. Assessed VRFs were hypertension, hyperlipidemia, diabetes, obesity, psychosocial factors, smoking habits, diet, alcohol intake, cardiac disease, and physical activity. RESULTS In total, 176 patients with INPH and 368 controls participated. Multivariable logistic regression analysis indicated that hyperlipidemia (odds ratio [OR] 2.380; 95% confidence interval [CI] 1.434-3.950), diabetes (OR 2.169; 95% CI 1.195-3.938), obesity (OR 5.428; 95% CI 2.502-11.772), and psychosocial factors (OR 5.343; 95% CI 3.219-8.868) were independently associated with INPH. Hypertension, physical inactivity, and cerebrovascular and peripheral vascular disease were also overrepresented in INPH. Moderate alcohol intake and physical activity were overrepresented among the controls. The population-attributable risk percentage was 24%. CONCLUSIONS Our findings confirm that patients with INPH have more VRFs and lack the protective factors present in the general population. Almost 25% of cases of INPH may be explained by VRFs. This suggests that INPH may be a subtype of vascular dementia. Targeted interventions against modifiable VRFs are likely to have beneficial effects on INPH.
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Affiliation(s)
- Hanna Israelsson
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden.
| | - Bo Carlberg
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden
| | - Carsten Wikkelsö
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden
| | - Katarina Laurell
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden
| | - Babar Kahlon
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden
| | - Göran Leijon
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden
| | - Anders Eklund
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden
| | - Jan Malm
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden
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In vitro performance of the fixed and adjustable gravity-assisted unit with and without motion-evidence of motion-induced flow. Acta Neurochir (Wien) 2016; 158:2011-8. [PMID: 27553048 DOI: 10.1007/s00701-016-2912-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 07/27/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Anti-siphon devices and gravitational-assisted valves have been introduced to counteract the effects of overdrainage after implantation of a shunt system. The study examined the flow performance of two gravitational-assisted valves (shunt assistant - SA and programmable shunt assistant - proSA, Miethke & Co. KG, Potsdam, Germany) in an in vitro shunt laboratory with and without motion. METHODS An in vitro laboratory setup was used to model the cerebrospinal fluid (CSF) drainage conditions similar to a ventriculo-peritoneal shunt and to test the SA (resistance of +20 cmH2O in 90°) and proSA (adjustable resistance of 0 to +40 cmH2O in 90°). The differential pressure (DP) through the simulated shunt and tested valve was adjusted between 0 and 60 cmH2O by combinations of different inflow pressures (40, 30, 20, 10, and 0 cmH2O) and the hydrostatic negative outflow pressure (0, -20, and -40 cmH2O) in several differing device positions (0°, 30°, 60°, and 90°). In addition, the two devices were tested under vertical motion with movement frequencies of 2, 3, and 4 Hz. RESULTS Both gravity-assisted units effectively counteract the hydrostatic effect in relation to the chosen differential pressure. The setting the proSA resulted in flow reductions in the 90° position according to the chosen resistance of the device. Angulation-related flow changes were similar in the two devices in 30-90° position, however, in the 0-30° position, a higher flow is seen in the proSA. Repeated vertical movement significantly increased flow through both devices. While with the proSA a 2-Hz motion was not able to induce additional flow (0.006 ± 0.05 ml/min), 3- and 4-Hz motion significantly induced higher flow values (3 Hz: +0.56 ± 0.12 ml/min, 4 Hz: +0.54 ± 0.04 ml/min). The flow through the SA was not induced by vertical movements at a low DP of 10 cmH2O at all frequencies, but at DPs of 30 cmH2O and higher, all frequencies significantly induced higher flow values (2 Hz: +0.36 ± 0.14 ml/min, 3 Hz: +0.32 ± 0.08 ml/min, 4 Hz: +0.28 ± 0.09 ml/min). CONCLUSIONS In a static setup, both tested valves effectively counteracted the hydrostatic effect according to their adjusted or predefined resistance in vertical position. Motion-induced increased flow was demonstrated for both devices with different patterns of flow depending on applied DP and setting of the respective valve. The documented increased drainage should be considered when selecting appropriate valves and settings in very active patients.
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Junkkari A, Häyrinen A, Rauramaa T, Sintonen H, Nerg O, Koivisto AM, Roine RP, Viinamäki H, Soininen H, Luikku A, Jääskeläinen JE, Leinonen V. Health-related quality-of-life outcome in patients with idiopathic normal-pressure hydrocephalus - a 1-year follow-up study. Eur J Neurol 2016; 24:58-66. [PMID: 27647684 DOI: 10.1111/ene.13130] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 08/09/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE This prospective study explored the factors affecting the health-related quality-of-life (HRQoL) outcome in patients with idiopathic normal-pressure hydrocephalus (iNPH) 1 year after the installation of the cerebrospinal fluid shunt. METHODS The HRQoL outcome was evaluated using a 15D instrument, in which the minimum clinically significant change/difference has been estimated to be ±0.015. The follow-up data (15D, Mini-Mental State Examination, Beck Depression Inventory, iNPH Grading Scale), frontal cortical biopsy, Charlson Age Comorbidity Index and body mass index of 145 patients diagnosed with iNPH by clinical and radiological examination were analyzed. RESULTS At 1-year follow-up, 63 (43%) patients had experienced a clinically significant improvement in HRQoL. Multivariate binary logistic regression analysis indicated that the absence of amyloid-β and hyperphosphorylated tau pathology in the frontal cortical biopsy (53% vs. 33%; absolute risk difference, 20%; adjusted odds ratio, 2.27; 95% confidence interval, 1.07-4.84; P < 0.05) and lower body mass index (adjusted odds ratio, 0.90, 95% confidence interval, 0.82-0.98; P < 0.05) predicted favorable HRQoL outcome 1 year after the shunting. CONCLUSIONS Less than half of the patients with iNPH experienced clinically significant favorable HRQoL outcome, partly explained by the patient's characteristics and comorbidities. The HRQoL approach reveals aspects that are important for the patient's well-being, but may also improve the quality of the outcome assessment of cerebrospinal fluid shunting. Study results may help clinicians to estimate which patients will benefit shunt surgery.
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Affiliation(s)
- A Junkkari
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - A Häyrinen
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - T Rauramaa
- Department of Pathology, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - H Sintonen
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - O Nerg
- Neurology of NeuroCenter, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - A M Koivisto
- Neurology of NeuroCenter, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - R P Roine
- Research Centre for Comparative Effectiveness and Patient Safety, University of Eastern Finland, Kuopio, Finland.,Group administration of the Hospital District of Helsinki and Uusimaa, Helsinki, Finland
| | - H Viinamäki
- Department of Psychiatry, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - H Soininen
- Department of Neurology, University of Eastern Finland, Kuopio, Finland
| | - A Luikku
- Neurology of NeuroCenter, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - J E Jääskeläinen
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - V Leinonen
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
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Gassner HG, Schwan F, Schebesch KM. Minimally invasive surgery of the anterior skull base: transorbital approaches. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2016; 14:Doc03. [PMID: 27453759 PMCID: PMC4940979 DOI: 10.3205/cto000118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Minimally invasive approaches are becoming increasingly popular to access the anterior skull base. With interdisciplinary cooperation, in particular endonasal endoscopic approaches have seen an impressive expansion of indications over the past decades. The more recently described transorbital approaches represent minimally invasive alternatives with a differing spectrum of access corridors. The purpose of the present paper is to discuss transorbital approaches to the anterior skull base in the light of the current literature. The transorbital approaches allow excellent exposure of areas that are difficult to reach like the anterior and posterior wall of the frontal sinus; working angles may be more favorable and the paranasal sinus system can be preserved while exposing the skull base. Because of their minimal morbidity and the cosmetically excellent results, the transorbital approaches represent an important addition to established endonasal endoscopic and open approaches to the anterior skull base. Their execution requires an interdisciplinary team approach.
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Affiliation(s)
- Holger G Gassner
- Department of Otolaryngology, Head & Neck Surgery, University Medicine of Regensburg, Germany
| | - Franziska Schwan
- Department of Otolaryngology, Head & Neck Surgery, University Medicine of Regensburg, Germany
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Birkeland P, Lauritsen J, Poulsen FR. Subdural haematoma complicating shunting for normal pressure hydrocephalus in the setting of concomitant antiplatelet medication - a report of 11 cases. Br J Neurosurg 2016; 30:567-70. [PMID: 27100934 DOI: 10.3109/02688697.2016.1173196] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To report on the occurrence and management of subdural haematoma after shunt implantation for normal pressure hydrocephalus and to determine the risk of recurrence in the setting of antiplatelet medication. METHODS From a consecutive series of 80 patients implanted with a cerebrospinal fluid shunt for normal pressure hydrocephalus, records from 11 patients taking antiplatelet drugs, who subsequently had surgery for subdural haematoma were extracted and retrospectively reviewed. RESULTS Patients were followed up for a mean of 1819 days after shunt implantation. Subdural haematomas occurred at a median of 335 days after shunt implantation - four ipsilateral, five contralateral and two bilateral with respect to the ventricular catheter. Three patients had reoperations done within a week without having resumed antiplatelet medication in the interim. One of them had three further reoperations done before the subdural collection disappeared. Only one patient had a late recurrence almost 11 years after shunt implantation. CONCLUSIONS Subdural haematoma in the setting of a ventriculoperitoneal implantation for normal pressure hydrocephalus and concomitant antiplatelet medication can be managed along usual lines. Antiplatelet medication can be recommenced in due course with a low risk of recurrence.
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Affiliation(s)
- Peter Birkeland
- a Department of Neurosurgery , Odense University Hospital , Odense , Denmark
| | - Jens Lauritsen
- b Department of Orthopaedic Surgery , Odense University Hospital , Odense , Denmark ;,c Institute of Clinical Research , University of Southern Denmark , Denmark
| | - Frantz Rom Poulsen
- a Department of Neurosurgery , Odense University Hospital , Odense , Denmark ;,c Institute of Clinical Research , University of Southern Denmark , Denmark
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Kim HS, Lee SU, Cha JH, Heo W, Song JS, Kim SJ. Clinical Analysis of Results of Shunt Operation for Hydrocephalus Following Traumatic Brain Injury. Korean J Neurotrauma 2015; 11:58-62. [PMID: 27169066 PMCID: PMC4847505 DOI: 10.13004/kjnt.2015.11.2.58] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 06/16/2015] [Accepted: 06/18/2015] [Indexed: 11/15/2022] Open
Abstract
Objective Ventricular enlargement following head injury is a frequent finding but cases requiring shunt operation are rare. The incidence and developing factors of post-traumatic hydrocephalus (PTH) have been variously reported, but studies for factors influencing outcomes of shunt operation for PTH are rare. The incidence of PTH requiring shunt operation, causing injuries, and factors influencing outcome of shunt operation need to be identified. Methods In total, 1,142 patients suffering from traumatic brain injury (TBI) between January 2007 and December 2012 were admitted to our department. Of them, 23 patients underwent shunt operation for diagnosed PTH. In this clinical study, we reviewed retrospectively our TBI database and in the 23 patients, we evaluated outcomes with Glasgow Outcome Score just before the operation, at 14 days, 3 months, and 6 months according to initial Glasgow Coma Scale (GCS) score, interval time between shunt operation and trauma, and lumbar cerebrospinal fluid (CSF) pressure. Results The incidence of PTH treated with shunt operation was 2.01%. Subdural hematoma (SDH) was the most common preceding head injury. The outcomes of shunt operation were not related with lumbar CSF pressure or interval time from trauma, but initial GCS score correlated with the outcome. Conclusion In present study, 2.01% of TBI patients underwent shunt operation. SDH was the most common preceding injury. Admission GCS score was related to the outcome of shunt operation. However, there were no correlation between the outcome of shunt operation and initial lumbar CSF pressure or interval time of shunt operation after the trauma.
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Affiliation(s)
- Ho Soo Kim
- Department of Neurosurgery, Wallace Memorial Baptist Hospital, Busan, Korea
| | - Sung Un Lee
- Department of Neurosurgery, Wallace Memorial Baptist Hospital, Busan, Korea
| | - Jae Hun Cha
- Department of Neurosurgery, Haedong Hospital, Busan, Korea
| | - Weon Heo
- Department of Neurosurgery, Busan Veterans Hospital, Busan, Korea
| | - Joon Suk Song
- Department of Neurosurgery, Wallace Memorial Baptist Hospital, Busan, Korea
| | - Sung Jin Kim
- Department of Neurosurgery, Wallace Memorial Baptist Hospital, Busan, Korea
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Svoboda SM, Park H, Naff N, Dorai Z, Williams MA, Youssef Y. Preventing Distal Catheter Obstruction in Laparoscopic Ventriculoperitoneal Shunt Placement in Adults: The “Falciform Technique”. J Laparoendosc Adv Surg Tech A 2015; 25:642-5. [PMID: 26186206 DOI: 10.1089/lap.2015.0196] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Shane M. Svoboda
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Habeeba Park
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Neal Naff
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Zeena Dorai
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland
| | | | - Yassar Youssef
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland
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Birkeland P, Lauritsen J, Poulsen FR. Aspirin is associated with an increased risk of subdural hematoma in normal-pressure hydrocephalus patients following shunt implantation. J Neurosurg 2015; 123:423-6. [DOI: 10.3171/2014.11.jns14804] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
In this paper the authors investigate whether shunt-treated patients with normal-pressure hydrocephalus receiving aspirin therapy are at increased risk of developing subdural hematoma (SDH).
METHODS
Records from 80 consecutive patients who had undergone implantation of a cerebrospinal fluid shunt for the treatment of normal-pressure hydrocephalus were retrospectively reviewed.
RESULTS
Eleven cases of symptomatic SDH occurred, all among patients receiving aspirin or clopidogrel. The 5-year survival estimate was 0.3 (p < 0.0001) for users of aspirin and the hazard ratio was 12.8 (95% CI 3.1–53).
CONCLUSIONS
Patients on an aspirin therapy regimen have a markedly increased risk of SDH after a shunt has been implanted for the treatment of normal-pressure hydrocephalus. Users of clopidogrel may have an even greater risk.
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Affiliation(s)
| | - Jens Lauritsen
- 2Orthopedic Surgery, Odense University Hospital; and
- 3Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Frantz Rom Poulsen
- Departments of 1Neurosurgery and
- 3Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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