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Rei KM, Ghauri MS, Uddin MB, Siddiqi J. Ventriculoperitoneal Shunt Failure and Cerebrospinal Fluid Protein: A Meta-Analysis and Systematic Review. Cureus 2024; 16:e54362. [PMID: 38500936 PMCID: PMC10945464 DOI: 10.7759/cureus.54362] [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: 01/06/2024] [Accepted: 02/17/2024] [Indexed: 03/20/2024] Open
Abstract
Ventriculoperitoneal shunts (VPS) are used to manage hydrocephalus but suffer from high failure rates. Our objectives were to (1) conduct a meta-analysis to objectively weigh this conflicting evidence, and (2) conduct a systematic review compiling and synthesizing what is known about the association between CSF proteins and shunt failure. A literature search was performed in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Embase, PubMed, and CENTRAL databases were searched from inception to June 2023. The articles were screened based on the inclusion criteria. A meta-analysis was conducted using R statistical software (R Foundation for Statistical Computing, Vienna, Austria); heterogeneity, subgroup, sensitivity, risk of bias, and publication bias analyses were performed. Thirty-one studies were selected for the systematic review, of which eight were selected for the meta-analysis. Perioperative CSF protein level was compared between 351 shunt failures and 1,094 shunt survivals; the mean difference of 24.37 mg/dL favoring shunt failure was significant (95% confidence interval=2.44-46.29 mg/dL). Our systematic review yielded a hypothesized pathogenesis: proteins attached to imperfections in the shunt surface lead to secondary attachment of cells, particularly astrocytes, and tertiary attachment of ependymal cells and the choroid plexus. Owing to the limitations of this meta-analysis, including lack of robustness due to missing data, heterogeneity, and certainty of the evidence, future research is needed to better understand the relationship between perioperative CSF protein levels and shunt failure.
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Affiliation(s)
- Kyle M Rei
- Neurosurgery, California University of Science and Medicine, Colton, USA
| | - Muhammad S Ghauri
- Neurosurgery, California University of Science and Medicine, Colton, USA
| | | | - Javed Siddiqi
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
- Neurosurgery, California University of Science and Medicine, Colton, USA
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2
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Simon TD, Sedano S, Rosenberg-Hasson Y, Durazo-Arvizu R, Whitlock KB, Hodor P, Hauptman JS, Limbrick DD, McDonald P, Ojemann JG, Maecker HT. Lower levels of Th1 and Th2 cytokines in cerebrospinal fluid (CSF) at the time of initial CSF shunt placement in children are associated with subsequent shunt revision surgeries. Cytokine 2023; 169:156310. [PMID: 37523803 PMCID: PMC10528342 DOI: 10.1016/j.cyto.2023.156310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/17/2023] [Accepted: 07/25/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVE We compare cytokine profiles at the time of initial CSF shunt placement between children who required no subsequent shunt revision surgeries and children requiring repeated CSF shunt revision surgeries for CSF shunt failure. We also describe the cytokine profiles across surgical episodes for children who undergo multiple subsequent revision surgeries. METHODS This pilot study was nested within an ongoing prospective multicenter study collecting CSF samples and clinical data at the time of CSF shunt surgeries since August 2014. We selected cases where CSF was available for children who underwent an initial CSF shunt placement and had no subsequent shunt revision surgeries during >=24 months of follow-up (n = 7); as well as children who underwent an initial CSF shunt placement and then required repeated CSF shunt revision surgeries (n = 3). Levels of 92 human cytokines were measured using the Olink immunoassay and 41 human cytokines were measured using Luminex based bead array on CSF obtained at the time of each child's initial CSF shunt placement and were displayed in heat maps. RESULTS Qualitatively similar profiles for the majority of cytokines were observed among the patients in each group in both Olink and Luminex assays. Lower levels of MCP-3, CASP-8, CD5, CXCL9, CXCL11, eotaxin, IFN-γ, IL-13, IP-10, and OSM at the time of initial surgery were noted in the children who went on to require multiple surgeries. Pro- and anti-inflammatory cytokines were selected a priori and shown across subsequent revision surgeries for the 3 patients. Cytokine patterns differed between patients, but within a given patient pro-inflammatory and anti-inflammatory cytokines acted in a parallel fashion, with the exception of IL-4. CONCLUSIONS Heat maps of cytokine levels at the time of initial CSF shunt placement for each child undergoing only a single initial CSF shunt placement and for each child undergoing repeat CSF shunt revision surgeries demonstrated qualitatively similar profiles for the majority of cytokines. Lower levels of MCP-3, CASP-8, CD5, CXCL9, CXCL11, eotaxin, IFN-γ, IL-13, IP-10, and OSM at the time of initial surgery were noted in the children who went on to require multiple surgeries. Better stratification by patient age, etiology, and mechanism of failure is needed to develop a deeper understanding of the mechanism of inflammation in the development of hydrocephalus and response to shunting in children.
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Affiliation(s)
- Tamara D Simon
- Children's Hospital Los Angeles, Los Angeles, CA, United States; Department of Pediatrics, University of Southern California, Los Angeles, CA, United States; The Saban Research Institute, Los Angeles, CA, United States.
| | - Sabrina Sedano
- Children's Hospital Los Angeles, Los Angeles, CA, United States; Currently University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Yael Rosenberg-Hasson
- Human Immune Monitoring Center, Stanford School of Medicine, Palo Alto, CA, United States
| | - Ramon Durazo-Arvizu
- Children's Hospital Los Angeles, Los Angeles, CA, United States; The Saban Research Institute, Los Angeles, CA, United States
| | | | | | - Jason S Hauptman
- Seattle Children's Research Institute, Seattle, WA, United States; Department of Neurosurgery, University of Washington, Seattle, WA, United States
| | - David D Limbrick
- St. Louis Children's Hospital, St. Louis, MO, United States; Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO, United States
| | - Patrick McDonald
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada; British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Jeffrey G Ojemann
- Seattle Children's Research Institute, Seattle, WA, United States; Department of Neurosurgery, University of Washington, Seattle, WA, United States
| | - Holden T Maecker
- Human Immune Monitoring Center, Stanford School of Medicine, Palo Alto, CA, United States
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A new inflammatory parameter can predict delayed intracranial hemorrhage following ventriculoperitoneal shunt. Sci Rep 2021; 11:13763. [PMID: 34215829 PMCID: PMC8253783 DOI: 10.1038/s41598-021-93315-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 06/23/2021] [Indexed: 12/14/2022] Open
Abstract
Delayed intracerebral hemorrhage (DICH) secondary to ventriculoperitoneal (VP) shunt is considered to be a potentially severe event. This study aimed to investigate the association between a ratio of postoperative neutrophil-to-lymphocyte ratio to preoperative neutrophil-to-lymphocyte ratio (NLRR) and DICH secondary to VP shunt. We performed a retrospective review of patients who underwent VP shunt between January 2016 and June 2020. Multivariable logistic regression analysis was used to assess the association of DICH and NLRR. Then patients were divided into two groups according to the optimal cut-off point of NLRR, propensity score matching (PSM) method was performed to reconfirm the result. A total of 130 patients were enrolled and DICH occurred in 29 patients. Elevated NLRR and history of craniotomy were independent risk factors for DICH secondary to VP shunt. The optimal cut off point of NLRR was 2.05, and the sensitivity was 89.7%, the specificity was 63.4%. Patients with NLRR > 2.05 had much higher incidence of DICH (40.6% vs 4.5%). Our finding suggested that DICH following VP shunt was not a rare complication and elevated NLRR could independently predict DICH. Inflammatory responses might play an important role in the development of DICH following VP shunt.
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Lanlokun MA, Guerriero E, Friedlander RM, Fajt ML. A case series of hypersensitivity reactions to ventriculoperitoneal shunt material. J Clin Neurosci 2021; 91:84-87. [PMID: 34373064 DOI: 10.1016/j.jocn.2021.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 11/15/2022]
Abstract
Hypersensitivity reactions to ventriculoperitoneal (VP) or lumboperitoneal (LP) shunts are rare. Symptoms often resolve following shunt replacement with a silicone-free hypoallergenic shunt. We describe novel cases of allergies to both standard and hypoallergenic shunts and highlight the utility of patch testing. Patient 1, a 24-year-old female with Chiari I malformation, developed diarrhea, abdominal pain, and rash along the LP shunt tract. Patch testing was positive. The shunt was replaced with a hypoallergenic VP shunt with symptom improvement. Five weeks later, she developed a new rash. Subsequent patch testing to the hypoallergenic shunt was positive. Patient 2, a 37-year-old female with Chiari I malformation, developed pruritus along the VP shunt tract. Patch testing to the standard shunt was positive. The shunt was replaced with a hypoallergenic shunt, with symptomatic improvement. One month later, she developed neck pain, headache, and pruritis. Patch testing to the hypoallergenic shunt was positive. The development of a pruritic rash along the shunt tract with or without gastrointestinal symptoms should prompt shunt allergy evaluation and consideration of patch testing to the shunt material.
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Affiliation(s)
- Mosopefoluwa A Lanlokun
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Montefiore Hospital, NW628, 3459 Fifth Avenue, Pittsburgh, PA 15213, United States.
| | - Emily Guerriero
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital, 200 Lothrop St., Fourth Floor, Suite B449, Pittsburgh, PA 15213, United States.
| | - Robert M Friedlander
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital, 200 Lothrop St., Fourth Floor, Suite B449, Pittsburgh, PA 15213, United States.
| | - Merritt L Fajt
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Montefiore Hospital, NW628, 3459 Fifth Avenue, Pittsburgh, PA 15213, United States.
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Gorelick NL, Serra R, Iyer R, Um R, Grewal A, Monroe A, Antoine H, Beharry K, Cecia A, Kroll F, Ishida W, Perdomo-Pantoja A, Xu R, Loth F, Ye X, Suk I, Tyler B, Bayston R, Luciano MG. Evaluating the Effects of Cerebrospinal Fluid Protein Content on the Performance of Differential Pressure Valves and Antisiphon Devices Using a Novel Benchtop Shunting Model. Neurosurgery 2021; 87:1046-1054. [PMID: 32521017 DOI: 10.1093/neuros/nyaa203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 03/17/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hydrocephalus is managed by surgically implanting flow-diversion technologies such as differential pressure valves and antisiphoning devices; however, such hardware is prone to failure. Extensive research has tested them in flow-controlled settings using saline or de-aerated water, yet little has been done to validate their performance in a setting recreating physiologically relevant parameters, including intracranial pressures, cerebrospinal fluid (CSF) protein content, and body position. OBJECTIVE To more accurately chart the episodic drainage characteristics of flow-diversion technology. A gravity-driven benchtop model of flow was designed and tested continuously during weeks-long trials. METHODS Using a hydrostatic pressure gradient as the sole driving force, interval flow rates of 6 valves were examined in parallel with various fluids. Daily trials in the upright and supine positions were run with fluid output collected from distal catheters placed at alternating heights for extended intervals. RESULTS Significant variability in flow rates was observed, both within specific individual valves across different trials and among multiple valves of the same type. These intervalve and intravalve variabilities were greatest during supine trials and with increased protein. None of the valves showed evidence of overt obstruction during 30 d of exposure to CSF containing 5 g/L protein. CONCLUSION Day-to-day variability of ball-in-cone differential pressure shunt valves may increase overdrainage risk. Narrow-lumen high-resistance flow control devices as tested here under similar conditions appear to achieve more consistent flow rates, suggesting their use may be advantageous, and did not demonstrate any blockage or trend of decreasing flow over the 3 wk of chronic use.
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Affiliation(s)
- Noah L Gorelick
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Riccardo Serra
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rajiv Iyer
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard Um
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Angad Grewal
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Audrey Monroe
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hannah Antoine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kelly Beharry
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Arba Cecia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Francesca Kroll
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wataru Ishida
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Francis Loth
- Department of Mechanical Engineering, University of Akron, Akron, Ohio
| | - Xiaobu Ye
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ian Suk
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Betty Tyler
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Roger Bayston
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Mark G Luciano
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Del Bigio MR, Sidhu RK, Kazina CJ, Serletis D. Inflammation and obstruction of distal catheter slits in ventriculoperitoneal shunts: likely role of graphite. J Neurosurg 2019; 133:1495-1502. [PMID: 31561214 DOI: 10.3171/2019.6.jns191082] [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: 04/18/2019] [Accepted: 06/25/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Tissue reactions that contribute to obstruction of peritoneal catheters in ventriculoperitoneal shunt systems are not well characterized. Several recent rapid obstructions in children prompted a retrospective quality assurance review. METHODS The authors conducted a detailed investigation of 22 surgically explanted peritoneal shunt catheters and 8 autopsy cases with documented distal shunt obstruction. Patients' medical histories were reviewed, and the catheters and/or tissues were subjected to conventional histological and immunohistochemical evaluations. In addition, 3 cases were subjected to electron microscopic examination including elemental analysis. RESULTS The majority of symptomatic obstructions were associated with distal slit catheters (17 slit, 3 open-end, and 2 unknown type). Among the autopsy cases, deaths were attributed to shunt failure in 2 cases of slit catheter obstruction, 1 case of open-end catheter obstruction, and 1 case of catheter withdrawal from the peritoneal cavity. The early tissue response consisted of a predominantly T lymphocyte accumulation with phagocytosis of graphite particles by macrophages. This is associated with proliferation of fibroblasts, mesothelial cells, and blood vessels, which can grow through the slits and occlude the catheter lumen. As the inflammation subsides after approximately 1 year, the tissue plug becomes collagenized and calcified. CONCLUSIONS This study, supported by experimental literature in other organ systems, indicates that graphite used to coat the slit openings of distal catheters from ventriculoperitoneal shunts likely predisposes to obstruction. Neurosurgeons and manufacturers should consider the potential negative consequences of this shunt design. The authors concur with previous recommendations that slit-valve distal catheters should not be used for ventriculoperitoneal shunting unless they can be proven safe and efficacious in a controlled trial.
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Affiliation(s)
- Marc R Del Bigio
- 1Department of Pathology, University of Manitoba
- 2Children's Hospital Research Institute of Manitoba
- 3SharedHealth Manitoba
| | | | - Colin J Kazina
- 5Section of Neurosurgery, University of Manitoba and Health Sciences Centre; and
| | - Demitre Serletis
- 5Section of Neurosurgery, University of Manitoba and Health Sciences Centre; and
- 6Manitoba Neurosurgery Laboratory, Children's Hospital Research Institute of Manitoba, Winnipeg, Mannitoba, Canada
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Case report: the unexpected culprit for multiple shunt revisions. Childs Nerv Syst 2019; 35:1063-1065. [PMID: 30806764 DOI: 10.1007/s00381-019-04089-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
Silicone allergy in patients with ventricular shunts is uncommon hence easily missed. However, there are clinical features that could assist in identifying and diagnosing this condition. We discuss a case where a patient with a ventriculoperitoneal (VP) shunt presented to us with features suggestive of silicone allergy.
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8
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Acute Sterile Canaliculitis: A Case Report and Review of the Literature. Ophthalmic Plast Reconstr Surg 2019; 35:e8-e9. [DOI: 10.1097/iop.0000000000001275] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Kurin M, Lee K, Gardner P, Fajt M, Umapathy C, Fasanella K. Clinical peritonitis from allergy to silicone ventriculoperitoneal shunt. Clin J Gastroenterol 2017; 10:229-231. [DOI: 10.1007/s12328-017-0729-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 02/23/2017] [Indexed: 11/24/2022]
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Deer TR, Pope JE, Hayek SM, Lamer TJ, Veizi IE, Erdek M, Wallace MS, Grider JS, Levy RM, Prager J, Rosen SM, Saulino M, Yaksh TL, De Andrés JA, Abejon Gonzalez D, Vesper J, Schu S, Simpson B, Mekhail N. The Polyanalgesic Consensus Conference (PACC): Recommendations for Intrathecal Drug Delivery: Guidance for Improving Safety and Mitigating Risks. Neuromodulation 2017; 20:155-176. [DOI: 10.1111/ner.12579] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 11/22/2016] [Accepted: 12/07/2016] [Indexed: 01/12/2023]
Affiliation(s)
| | | | - Salim M. Hayek
- University Hospitals Cleveland Medical Center, Case Western Reserve University; Cleveland OH USA
| | | | - Ilir Elias Veizi
- Veterans Administration Medical Center, Case Western Reserve University; Cleveland OH USA
| | - Michael Erdek
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine; Baltimore MD USA
| | | | - Jay S. Grider
- UK HealthCare Pain Services, University of Kentucky College of Medicine; Lexington KY USA
| | | | - Joshua Prager
- Center for the Rehabilitation of Pain Syndromes (CRPS) at UCLA Medical Plaza; Los Angeles CA USA
| | | | | | - Tony L. Yaksh
- Anesthesiology and Pharmacology, University of California; San Diego CA USA
| | - Jose A. De Andrés
- Valencia School of Medicine, Hospital General Universitario; Valencia Spain
| | | | - Jan Vesper
- Neurochirurgische Klinik, Universitätsklinikum Düsseldorf; Germany
| | | | - Brian Simpson
- Department of Neurosurgery; University Hospital of Wales; Cardiff UK
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Hanak BW, Ross EF, Harris CA, Browd SR, Shain W. Toward a better understanding of the cellular basis for cerebrospinal fluid shunt obstruction: report on the construction of a bank of explanted hydrocephalus devices. J Neurosurg Pediatr 2016; 18:213-23. [PMID: 27035548 PMCID: PMC5915300 DOI: 10.3171/2016.2.peds15531] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Shunt obstruction by cells and/or tissue is the most common cause of shunt failure. Ventricular catheter obstruction alone accounts for more than 50% of shunt failures in pediatric patients. The authors sought to systematically collect explanted ventricular catheters from the Seattle Children's Hospital with a focus on elucidating the cellular mechanisms underlying obstruction. METHODS In the operating room, explanted hardware was placed in 4% paraformaldehyde. Weekly, samples were transferred to buffer solution and stored at 4°C. After consent was obtained for their use, catheters were labeled using cell-specific markers for astrocytes (glial fibrillary acidic protein), microglia (ionized calcium-binding adapter molecule 1), and choroid plexus (transthyretin) in conjunction with a nuclear stain (Hoechst). Catheters were mounted in custom polycarbonate imaging chambers. Three-dimensional, multispectral, spinning-disk confocal microscopy was used to image catheter cerebrospinal fluid-intake holes (10× objective, 499.2-μm-thick z-stack, 2.4-μm step size, Olympus IX81 inverted microscope with motorized stage and charge-coupled device camera). Values are reported as the mean ± standard error of the mean and were compared using a 2-tailed Mann-Whitney U-test. Significance was defined at p < 0.05. RESULTS Thirty-six ventricular catheters have been imaged to date, resulting in the following observations: 1) Astrocytes and microglia are the dominant cell types bound directly to catheter surfaces; 2) cellular binding to catheters is ubiquitous even if no grossly visible tissue is apparent; and 3) immunohistochemical techniques are of limited utility when a catheter has been exposed to Bugbee wire electrocautery. Statistical analysis of 24 catheters was performed, after excluding 7 catheters exposed to Bugbee wire cautery, 3 that were poorly fixed, and 2 that demonstrated pronounced autofluorescence. This analysis revealed that catheters with a microglia-dominant cellular response tended to be implanted for shorter durations (24.7 ± 6.7 days) than those with an astrocyte-dominant response (1183 ± 642 days; p = 0.027). CONCLUSIONS Ventricular catheter occlusion remains a significant source of shunt morbidity in the pediatric population, and given their ability to intimately associate with catheter surfaces, astrocytes and microglia appear to be critical to this pathophysiology. Microglia tend to be the dominant cell type on catheters implanted for less than 2 months, while astrocytes tend to be the most prevalent cell type on catheters implanted for longer time courses and are noted to serve as an interface for the secondary attachment of ependymal cells and choroid plexus.
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Affiliation(s)
- Brian W. Hanak
- Center for Integrative Brain Research, Seattle Children’s Research Institute,Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Emily F. Ross
- Center for Integrative Brain Research, Seattle Children’s Research Institute
| | - Carolyn A. Harris
- Department of Neurosurgery, Wayne State University, Detroit, Michigan
| | - Samuel R. Browd
- Center for Integrative Brain Research, Seattle Children’s Research Institute,Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - William Shain
- Center for Integrative Brain Research, Seattle Children’s Research Institute,Department of Neurological Surgery, University of Washington, Seattle, Washington
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12
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Rajasekaran S, Hongwei Qu, Zakalik K. Thermal measurement of cerebrospinal fluid flow rate in hydrocephalus shunt. 2015 IEEE SENSORS 2015. [DOI: 10.1109/icsens.2015.7370415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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13
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Cheatle JT, Bowder AN, Tefft JL, Agrawal SK, Hellbusch LC. Effect of Protein Concentration on the Flow of Cerebrospinal Fluid Through Shunt Tubing. Neurosurgery 2015; 77:972-8. [DOI: 10.1227/neu.0000000000000956] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND:
Protein levels in cerebrospinal fluid (CSF) are commonly thought to be related to sterile shunt malfunction.
OBJECTIVE:
To investigate the relationship between protein concentration and flow through CSF shunt tubing and a shunt valve.
METHODS:
New and explanted shunt catheters were tested with and without a shunt valve attached at various protein concentrations. The protein concentrations used were 0.5, 2, 5, and 10 g/L. A flask with artificial CSF attached to the proximal end provided flow. The flow was allowed to stabilize over 1 hour, and then the change in pressure between the proximal and distal end of the catheter was measured and recorded. The resistance to flow was calculated for new and explanted catheters for adult shunt systems, as well as with the addition of a programmable siphon control valve. The resistance was examined after the addition of various protein concentrations to a normal CSF solution.
RESULTS:
Both new and explanted catheters exhibited a decrease in the resistance to flow with higher concentrations of protein.
CONCLUSION:
In our laboratory setting, there was decreased resistance of adult CSF shunt catheters with and without a valve as the concentration of protein in the CSF increased. The decrease in the resistance of CSF shunt catheters with the addition of protein to the CSF may be related to the lowering of surface tension. This is the first study to examine the effects of varying protein concentrations across different lengths of shunt tubing for both new and explanted catheters.
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Affiliation(s)
- Joseph T. Cheatle
- Division of Neurosurgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
- Current: Grand Strand Spine & Neuro Center, Grand Strand Medical Center, Myrtle Beach, South Carolina
| | - Alexis N. Bowder
- Division of Neurosurgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jonathan L. Tefft
- Division of Neurosurgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Sandeep K. Agrawal
- Division of Neurosurgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Leslie C. Hellbusch
- Division of Neurosurgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
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Symss NP, Oi S. Is there an ideal shunt? A panoramic view of 110 years in CSF diversions and shunt systems used for the treatment of hydrocephalus: from historical events to current trends. Childs Nerv Syst 2015; 31:191-202. [PMID: 25547875 DOI: 10.1007/s00381-014-2608-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 12/09/2014] [Indexed: 11/24/2022]
Abstract
OBJECT The goal of this study is to evaluate whether an "ideal shunt" exists. METHODS This is a retrospective analysis based on original papers in the field of Hydrocephalus and Shunts. Patients of all age groups, who had hydrocephalus, and underwent some form of CSF diversion were included. The study has been divided into four stages: from 1900 to 1949, 1950 to 1974, 1975 to 1999, and from 2000 to 2010. RESULTS In stage 1 (historical era): Saphenous vein grafts, rubber conduits, and other materials were used in CSF diversions. In 1949, the first implantable shunt tube was developed by Nulsen. In stage 2 (experimental stage): the Holter valve was developed. Newer innovations were developed in relation to the ventriculo-atrial shunt, which was the preferred CSF diversion. In stage 3 (developmental stage), a large number of different design shunt systems were developed, with the aim of reducing complications. The ventriculo-peritoneal shunt had become the preferred CSF diversion. Also, the programmable valve was born. In stage 4 (era of programmable valve, there is a preference for the use of programmable shunt systems. However, shunt failure rate at 1 year being around 25 to 40%, and shunt survival at 1 and 2 years are 50-70 and 47-53% in most series. CONCLUSION Every shunt is an ideal shunt provided the choice of the shunt used should be made by the matching performance of the shunt system to the altered profile of CSF dynamics of a given patient. The most important factor being the opening pressure.
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Affiliation(s)
- Nigel Peter Symss
- Division of Pediatric Neurosurgery, Global Neurosciences, Global Health City, Cheran Nagar, Perumbakkam, Sholinganallur Road, Chennai, 600 100, Tamil Nadu, India,
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Rajasekaran S, Kovar S, Qu P, Inwald D, Williams E, Qu H, Zakalik K. Mechanism for measurement of flow rate of cerebrospinal fluid in hydrocephalus shunts. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2015; 2014:2153-6. [PMID: 25570411 DOI: 10.1109/embc.2014.6944043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The measurement of the flow rate of cerebrospinal fluid (CSF) or existence of CSF flow inside the shunt tube after shunt implant have been reported as tedious process for both patients and doctors; this paper outlines a potential in vitro flow rate measurement method for CSF in the hydrocephalus shunt. The use of implantable titanium elements in the shunt has been proposed to allow for an accurate temperature measurement along the shunt for prediction of CSF flow rate. The CSF flow velocity can be deduced by decoupling the thermal transfer in the measured differential time at a pair of measurement spots of the titanium elements. Finite element analyses on the fluidic and thermal behaviors of the shunt system have been conducted. Preliminary bench-top measurements on a simulated system have been carried out. The measured flow rates, ranging from 0.5 mm/sec to 1.0 mm/sec, which is clinically practical, demonstrate good agreements with the simulation results.
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Mattei TA, Rehman AA. "Extremely minimally invasive": recent advances in nanotechnology research and future applications in neurosurgery. Neurosurg Rev 2014; 38:27-37; discussion 37. [PMID: 25173621 DOI: 10.1007/s10143-014-0566-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 05/20/2014] [Accepted: 06/22/2014] [Indexed: 12/25/2022]
Abstract
The term "nanotechnology" refers to the development of materials and devices that have been designed with specific properties at the nanometer scale (10(-9) m), usually being less than 100 nm in size. Recent advances in nanotechnology have promised to enable visualization and intervention at the subcellular level, and its incorporation to future medical therapeutics is expected to bring new avenues for molecular imaging, targeted drug delivery, and personalized interventions. Although the central nervous system presents unique challenges to the implementation of new therapeutic strategies involving nanotechnology (such as the heterogeneous molecular environment of different CNS regions, the existence of multiple processing centers with different cytoarchitecture, and the presence of the blood-brain barrier), numerous studies have demonstrated that the incorporation of nanotechnology resources into the armamentarium of neurosurgery may lead to breakthrough advances in the near future. In this article, the authors present a critical review on the current 'state-of-the-art' of basic research in nanotechnology with special attention to those issues which present the greatest potential to generate major therapeutic progresses in the neurosurgical field, including nanoelectromechanical systems, nano-scaffolds for neural regeneration, sutureless anastomosis, molecular imaging, targeted drug delivery, and theranostic strategies.
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Affiliation(s)
- Tobias A Mattei
- Department of Neurosurgery, Brain & Spine Center-InvisionHealth/Buffalo-NY, 400 International Dr., Buffalo, NY, ZIP 14221, USA,
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Lee H, Kolahi K, Bergsneider M, Judy JW. Mechanical Evaluation of Unobstructing Magnetic Microactuators for Implantable Ventricular Catheters. JOURNAL OF MICROELECTROMECHANICAL SYSTEMS : A JOINT IEEE AND ASME PUBLICATION ON MICROSTRUCTURES, MICROACTUATORS, MICROSENSORS, AND MICROSYSTEMS 2014; 23:795-802. [PMID: 29151776 PMCID: PMC5693250 DOI: 10.1109/jmems.2014.2321377] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Here, we report on the development and evaluation of novel unobstructing magnetic microactuators for maintaining the patency of implantable ventricular catheters used in hydrocephalus application. The treatment of hydrocephalus requires chronic implantation of a shunt system to divert excess cerebrospinal fluid from the brain. These shunt systems suffer from a high failure rate (>40%) within the first year of implantation, often due to biological accumulation. Previously, we have shown that magnetic microactuators can be used to remove biological blockage. The new cantilever-based magnetic microactuator presented in this paper improves upon the previous torsional design using a bimorph to induce a postrelease out-of-plane deflection that will prevent the device from occluding the pore at rest. The mechanical evaluations (i.e., postrelease deflection, static and dynamic responses) of fabricated devices are reported and compared with theoretical values.
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Affiliation(s)
- Hyowon Lee
- NeuroEngineering Training Program, Biomedical Engineering Interdepartmental Program, University of California at Los Angeles, Los Angeles, CA 90095 USA. He is now with the St. Jude Medical, Implantable Electronic Systems Division, Plano, TX 75024 USA
| | - Kameran Kolahi
- Mathematics Department, University of California at Los Angeles, Los Angeles, CA 90095 USA
| | - Marvin Bergsneider
- NeuroEngineering Training Program, Biomedical Engineering Interdepartmental Program, Neurosurgery, School of Medicine, University of California at Los Angeles, Los Angeles, CA 90095 USA
| | - Jack W Judy
- NeuroEngineering Training Program, Biomedical Engineering Interdepartmental Program, Department of Electrical Engineering, University of California at Los Angeles, Los Angeles, CA 90095 USA. He is now with the Nanoscience Institute for Medical and Engineering Technology, University of Florida, Gainesville, FL 32611 USA
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Portillo ME, Corvec S, Borens O, Trampuz A. Propionibacterium acnes: an underestimated pathogen in implant-associated infections. BIOMED RESEARCH INTERNATIONAL 2013; 2013:804391. [PMID: 24308006 PMCID: PMC3838805 DOI: 10.1155/2013/804391] [Citation(s) in RCA: 188] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 08/20/2013] [Accepted: 10/04/2013] [Indexed: 12/16/2022]
Abstract
The role of Propionibacterium acnes in acne and in a wide range of inflammatory diseases is well established. However, P. acnes is also responsible for infections involving implants. Prolonged aerobic and anaerobic agar cultures for 14 days and broth cultures increase the detection rate. In this paper, we review the pathogenic role of P. acnes in implant-associated infections such as prosthetic joints, cardiac devices, breast implants, intraocular lenses, neurosurgical devices, and spine implants. The management of severe infections caused by P. acnes involves a combination of antimicrobial and surgical treatment (often removal of the device). Intravenous penicillin G and ceftriaxone are the first choice for serious infections, with vancomycin and daptomycin as alternatives, and amoxicillin, rifampicin, clindamycin, tetracycline, and levofloxacin for oral treatment. Sonication of explanted prosthetic material improves the diagnosis of implant-associated infections. Molecular methods may further increase the sensitivity of P. acnes detection. Coating of implants with antimicrobial substances could avoid or limit colonization of the surface and thereby reduce the risk of biofilm formation during severe infections. Our understanding of the role of P. acnes in human diseases will likely continue to increase as new associations and pathogenic mechanisms are discovered.
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Affiliation(s)
| | - Stéphane Corvec
- Service de Bactériologie-Hygiène, CHU de Nantes, Institut de Biologie, Nantes Cedex, France
- Université de Nantes, EA3826, Thérapeutiques Cliniques et Expérimentales des Infections, 1 rue G. Veil, 44000 Nantes, France
| | - Olivier Borens
- Orthopedic Septic Surgical Unit, Department of Surgery and Anesthesiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Free University and Humboldt University, Charitéplatz 1, 10117 Berlin, Germany
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Pathophysiology of shunt dysfunction in shunt treated hydrocephalus. Acta Neurochir (Wien) 2013; 155:1763-72. [PMID: 23645322 DOI: 10.1007/s00701-013-1729-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 04/15/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND We hypothesized that shunt dysfunction in the ventricular catheter and the shunt valve is caused by different cellular responses. We also hypothesized that the cellular responses depend on different pathophysiological mechanisms. METHODS Removed shunt material was collected. Macroscopic tissue in the catheters was paraffin-embedded and HE-stained. Valves were incubated with trypsin-EDTA in order to detach macroscopically invisible biomaterial, which was then cytospinned and HE-stained. Associated aetiological and surgical data were collected by reviewing patient files, and ventricular catheter position was examined using preoperative radiology (CT scans). RESULTS We examined eleven ventricular catheters and ten shunt valves. Catheters: 6/11 catheters contained intraluminal tissue consisting of vascularised glial tissue and inflammatory cells (macrophages/giant cells and a few eosinophils). Catheter adherence correlated with the presence of intraluminal tissue, and all tissue containing catheters had some degree of ventricle wall contact. All obstructed catheters contained intraluminal tissue, except one catheter that was dysfunctional because of lost ventricular contact. Valves: Regardless of intraoperative confirmation of valve obstruction, all ten valves contained an almost uniform cellular response of glial cells (most likely ependymal cells), macrophages/giant cells, and lymphomonocytic cells. Some degree of ventricle wall catheter contact was present in all examined valves with available radiology (9/10). CONCLUSIONS The same cellular responses (i.e., glial cells and inflammatory cells) cause both catheter obstruction and valve obstruction. We propose two synergistic pathophysiological mechanisms. (1) Ventricle wall/parenchymal contact by the catheter causes mechanical irritation of the parenchyma including ependymal exfoliation. (2) The shunt material provokes an inflammatory reaction, either nonspecific or specific. In combination, these mechanisms cause obstructive tissue ingrowth (glial and inflammatory) in the catheter and clogging of the valve by exfoliated glial cells and reactive inflammatory cells.
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20
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Kehler U, Langer N, Gliemroth J, Meier U, Lemcke J, Sprung C, Schlosser HG, Kiefer M, Eymann R, Heese O. Reduction of shunt obstructions by using a peel-away sheath technique? A multicenter prospective randomized trial. Clin Neurol Neurosurg 2012; 114:381-4. [DOI: 10.1016/j.clineuro.2011.11.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 09/29/2011] [Accepted: 11/13/2011] [Indexed: 11/24/2022]
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Cheatle JT, Bowder AN, Agrawal SK, Sather MD, Hellbusch LC. Flow characteristics of cerebrospinal fluid shunt tubing. J Neurosurg Pediatr 2012; 9:191-7. [PMID: 22295926 DOI: 10.3171/2011.11.peds11255] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cerebrospinal fluid shunt systems malfunction for a multitude of reasons, including malpostitioning, obstruction of the ventricular or distal catheter, obstruction of the shunt valve, and catheter disruptions or disconnections. The goal of this study was to examine the hydrodynamic resistance and flow in new and explanted catheters and also in catheters with 1 or 2 straight connectors. METHODS Explanted catheters of multiple lengths, 2-piece catheters, 3-piece catheters, and new catheters were attached to a proximal and distal manometer. A flask with artificial CSF attached to the proximal end provided flow. The flow was allowed to stabilize over 1 hour; then the change in pressure between the proximal and distal end of the catheter was measured. RESULTS The resistance to flow was calculated for new, never-implanted catheters and compared with the resistance of explanted distal shunt catheters. The resistance of the new catheters was examined after the addition of 1 and 2 straight connectors. Explanted catheters exhibited a slight increase in the resistance to flow of artificial CSF compared with new catheters. Two-piece and 3-piece catheters had a significant increase in resistance to flow compared with new catheters. For all catheters, resistance to flow increased as length increased (new, p = 0.01; explanted, p = 0.009; 1 connector, p = 0.01; 2 connectors, p = 0.03). In this paper, effective diameter is defined as the available cross-sectional area of catheter contacted by the artificial CSF. For new and explanted catheters, a decrease in the effective diameter of the catheter was associated with an increase in the resistance to flow of artificial CSF (new, p = 0.1083; explanted, p = 0.0091). However, after the addition of 1 or 2 connectors, an inverse trend was observed: resistance to flow increased with effective diameter. CONCLUSIONS There appears to be some increase in resistance of CSF shunt catheters as they age, altering flow dynamics. In addition, the use of straight connectors within a CSF shunt system increases the resistance to flow of artificial CSF within the shunt system. The increase in resistance appears to be related to the duration of implantation and the length of the catheter and inversely related to the diameter of the catheter. This increase in resistance may be related to sterile shunt malfunction. The addition of straight connectors is associated with a significant increase in resistance in comparison with catheters without connectors (p = 0.005).
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Affiliation(s)
- Joseph T Cheatle
- Division of Neurosurgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska 68198-6250, USA
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22
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Miele VJ, Price KO, Bloomfield S, Hogg J, Bailes JE. A review of intrathecal morphine therapy related granulomas. Eur J Pain 2012; 10:251-61. [PMID: 15964775 DOI: 10.1016/j.ejpain.2005.05.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2005] [Revised: 04/25/2005] [Accepted: 05/05/2005] [Indexed: 11/16/2022]
Abstract
The development of catheter associated granulomatous masses in intrathecal morphine therapy is an uncommon, but potentially serious problem. While these systems have historically been used in patients with short life expectancies, more recently patients with pain from a benign source have benefited from this therapy, and new complications are being encountered secondary to the patients' longer life spans. Morphine is the most commonly used intrathecal opioid and evidence exists that the formation of granulomatous masses are related to the use of higher doses. When the patients' requirement of morphine increases significantly, the physician should be alert for signs of spinal cord compression, such as new neurological deficits, myelopathy, or radiculopathy. Patients that require these higher doses should be properly informed of the association with granulomas and their associated risks. Indolent infection may also be the etiology of granulomatous masses, and the presence of organisms, both aerobic and anaerobic, should be routinely investigated. Patients with catheter-associated granulomas appear to share several features. They exhibit the onset of symptoms several months following the initiation of intraspinal opioids and commonly present with an increase in pain that precedes signs and symptoms of neurological deterioration. While MRI might be the preferred method of detection of intrathecal granulomas, its cost and availability are prohibitive for routine screening. CT myelogram via pump side port injection of contrast can also be performed to detect catheter tip related granulomas/obstructions. Serial neurological examinations for new deficits may be performed and recorded during pump refill visits to recognize a granulomatous mass in its early stages. If an abnormality is identified, imaging studies are appropriate. Awareness of the condition and vigilance are the keys to successful management of this complication.
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Affiliation(s)
- Vincent J Miele
- Department of Neurosurgery, West Virginia University School of Medicine, P.O. Box 9183, Morgantown, WV 26506-9183, USA.
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Harris CA, McAllister JP. What We Should Know About the Cellular and Tissue Response Causing Catheter Obstruction in the Treatment of Hydrocephalus. Neurosurgery 2011; 70:1589-601; discussion 1601-2. [DOI: 10.1227/neu.0b013e318244695f] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
The treatment of hydrocephalus by cerebrospinal fluid shunting is plagued by ventricular catheter obstruction. Shunts can become obstructed by cells originating from tissue normal to the brain or by pathological cells in the cerebrospinal fluid for a variety of reasons. In this review, the authors examine ventricular catheter obstruction and identify some of the modifications to the ventricular catheter that may alter the mechanical and chemical cues involved in obstruction, including alterations to the surgical strategy, modifications to the chemical surface of the catheter, and changes to the catheter architecture. It is likely a combination of catheter modifications that will improve the treatment of hydrocephalus by prolonging the life of ventricular catheters to improve patient outcome.
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Affiliation(s)
- Carolyn A. Harris
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Salt Lake City, Utah
- Department of Bioengineering, University of Utah, Salt Lake City, Utah
| | - James P. McAllister
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Salt Lake City, Utah
- Department of Bioengineering, University of Utah, Salt Lake City, Utah
- Department of Physiology, University of Utah, Salt Lake City, Utah
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Examination of deposits in cerebrospinal fluid shunt valves using scanning electron microscopy. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 113:83-5. [PMID: 22116429 DOI: 10.1007/978-3-7091-0923-6_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Obstruction remains the most common complication of cerebrospinal fluid shunts. The valve constitutes an important site of potential malfunction. The aim of this pilot study was to investigate the extent and composition of debris depositions along the structural components of the shunt valve.We examined three explanted Medos programmable valves. The valves were stored and examined wet. They were cut open and disassembled. All specimens were studied under a scanning electron microscope (SEM; Quanta 200; FEI, Hillsboro, OR, USA) operating at different levels of accelerating voltage and 110 μA beam current. Valve areas analyzed included the ruby ball and collar, the flat spring with its pillar, and the staircase cam. The elemental composition, in areas with abnormal deposits, was subsequently determined by energy-dispersive X-ray microanalysis (EDS) using a Si (Li) detector (Sapphire; EDAX, Mahwah, NJ, USA) with a super ultrathin Be window.All explanted valves had varying degrees of deposits in all surveyed areas. The extent of the deposits was not related to the time since implantation. The effect of these deposits on proper functioning of the valve as well as their pathogenesis is difficult to establish.
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Bezerra S, Frigeri TM, Severo CM, Santana JCB, Graeff-Teixeira C. Cerebrospinal fluid eosinophilia associated with intraventricular shunts. Clin Neurol Neurosurg 2011; 113:345-9. [PMID: 21492998 DOI: 10.1016/j.clineuro.2011.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2010] [Revised: 01/08/2011] [Accepted: 03/12/2011] [Indexed: 11/25/2022]
Abstract
CSF eosinophilia (CSF-eo) is uncommon and is usually caused by helminthic infections. However, it has also been found in ∼30% of patients experiencing intraventricular shunt malfunctions. We present a case report and review the conditions associated with CSF-eo and their prophylaxis. An 8 year-old boy with tetraventricular hydrocephalus has had several shunt malfunctions over the last three years. During hospitalization in January 2009 for shunt revision, a transient 30% eosinophilia was detected in his cerebral spinal fluid (CSF) concomitant with Staphylococcus epidermidis infection and long term vancomycin administration. After several shunt replacements and antibiotic treatment, CSF-eo eventually disappeared with good overall clinical response. CSF-eo is a transient and focal event mainly associated with infection, reactions to foreign substances, particles or blood, or obstruction of tubing by normal or fibro-granulomatous tissues. Infection associated with CSF-eo is usually caused by S. epidermidis and Propioniumbacterium acnes. In addition to infection, allergy to silicone and other foreign materials may also be a cause of CSF-eo. We review the diversity of conditions and proposed mechanisms associated with CSF-eo, as well as recommendations for the care of patients with shunts. Detection of CSF-eo has been shown to be a useful indicator of shunt malfunction. As such, it provides physicians with an indicator of a hypersensitivity reaction that is underway or the need to identify bacterial infection. We also highlight the need for improved biocompatibility of shunt hardware and describe strategies to avoid conditions leading to shunt malfunction.
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Affiliation(s)
- Sofia Bezerra
- Grupo de Parasitologia Biomédica da PUCRS, Avenida Ipiranga 6690, 90690 900 Porto Alegre, RS, Brazil
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Harris CA, Resau JH, Hudson EA, West RA, Moon C, Black AD, McAllister JP. Effects of surface wettability, flow, and protein concentration on macrophage and astrocyte adhesion in an in vitro model of central nervous system catheter obstruction. J Biomed Mater Res A 2011; 97:433-40. [DOI: 10.1002/jbm.a.33078] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Revised: 01/21/2011] [Accepted: 01/31/2011] [Indexed: 11/07/2022]
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Schuchard M, Lanning R, North R, Reig E, Krames E. Neurologic Sequelae of Intraspinal Drug Delivery Systems: Results of a Survey of American Implanters of Implantable Drug Delivery Systems. Neuromodulation 2010; 1:137-48. [DOI: 10.1111/j.1525-1403.1998.tb00007.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kolić Z, Kukuljan M, Bonifačić D, Vukas D. CSF liver pseudocyst as a complication of a ventriculoperitoneal shunt. Wien Klin Wochenschr 2010; 122:641-4. [DOI: 10.1007/s00508-010-1474-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2010] [Accepted: 08/31/2010] [Indexed: 10/18/2022]
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Harris CA, Resau JH, Hudson EA, West RA, Moon C, McAllister JP. Mechanical contributions to astrocyte adhesion using a novel in vitro model of catheter obstruction. Exp Neurol 2010; 222:204-10. [PMID: 20051241 DOI: 10.1016/j.expneurol.2009.12.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Revised: 12/22/2009] [Accepted: 12/23/2009] [Indexed: 02/06/2023]
Abstract
Drainage and diversion of cerebrospinal fluid (CSF) through shunt systems is the most common treatment for hydrocephalus, but complications due to tissue obstruction of the catheter occur in up to 61% of patients. Although shunt systems have undergone limited technological advancements to resist mammalian cell adhesion, there is a need to further reduce adhesion that can exacerbate obstruction. The high intrinsic variability in clinical studies and an inability to predict chronic adhesion of host cells in vitro while maintaining the environmental conditions observed in hydrocephalus have impeded progress. We designed the hydrocephalus shunt catheter bioreactor (HSCB) to measure inflammatory cell adhesion under experimentally manipulated conditions of CSF pressure, pulsation rate, and flow rates. For a 20-h period, astrocytes were perfused through the pulsatile flow system, and adhesion on silicone catheters was recorded. These results were compared with those obtained under static cell culture conditions. Astrocyte adhesion was significantly increased under conditions of increased flow rate (0.25 and 0.30 mL/min), and a trend toward increased adhesion was observed under conditions of elevated pressure and pulsation rate. Because the HSCB represents physiologic conditions more accurately than static cell culture, our results suggest that standard static cell culturing techniques are insufficient to model inflammatory cell adhesion on catheters used in the treatment of hydrocephalus and that changes to the ventricular microenvironment can alter the mechanisms of cellular adhesion. The HSCB represents a relevant test system and is an effective model system for the analysis of cellular adhesion and occlusion of shunt catheters.
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Affiliation(s)
- Carolyn A Harris
- Department of Bioengineering, University of Utah, Salt Lake City, UT 84112, USA.
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Abstract
OBJECT Eosinophils have been reported in children with cerebrospinal fluid (CSF) shunts. The goal of this study was to describe the risk factors, relationship to infection, and clinical significance of CSF eosinophilia in a large group of shunt-treated patients. METHODS The authors performed a retrospective review of data obtained in all patients who underwent ventricular shunt placement or revision at the James Whitcomb Riley Hospital for Children between 2000 and 2004. RESULTS Eosinophils were identified during a follow-up shunt evaluation in 93 (31%) of 300 patients after initial shunt placement. Eosinophilia was statistically related to CSF extravasation (p < 0.0001), shunt infection (p = 0.031), blood in CSF (p < 0.0001), younger age at shunt insertion (p = 0.030), and the diagnosis of posthemorrhagic hydrocephalus (p < 0.0001). Patients with CSF eosinophilia had a higher risk of subsequent shunt failure (p < 0.0001). Analysis was performed using data obtained in a cohort of patients with a total of 130 shunt infections. Cerebrospinal fluid eosinophils were identified in 118 infections (90.8%). The leukocytic and eosinophilic reactions were dependent on the infecting organism. Propionibacterium acnes had a statistically lower CSF leukocyte count but higher differential percentage of eosinophils than the other common pathogens. CONCLUSIONS Cerebrospinal fluid eosinophilia is a relatively common finding in children with shunts. Patients with CSF eosinophilia had an increased risk of shunt malfunction in the present series. Eosinophilia is associated with infection, CSF extravasation, and blood in the CSF. Patients with P. acnes-induced shunt infections have higher eosinophil percentages than are found in infections associated with other common organisms. Therefore, in patients with eosinophilia, extended anaerobic culture studies should be performed with particular attention paid to searching for this pathogen.
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Affiliation(s)
- Daniel H Fulkerson
- Department of Neurosurgery, Division of Pediatric Neurosurgery, James Whitcomb Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
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Lee SA, Vasquez DJ, Bergsneider M, Judy JW. Magnetic microactuators for MEMS-enabled ventricular catheters for hydrocephalus. CONFERENCE PROCEEDINGS : ... ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL CONFERENCE 2008; 2006:2494-7. [PMID: 17946960 DOI: 10.1109/iembs.2006.259879] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The most common treatment for patients with hydrocephalus is the surgical implantation of a cerebrospinal fluid (CSF) shunt. Unfortunately, this device, which is critical for lowering intracranial pressure, has a substantial failure rate (40% in the first year). A leading cause of failure is the obstruction of the ventricular catheter. The goal of this project is to design a ventricular catheter that will resist occlusion through the use of micromachining and micro electro-mechanical systems (MEMS) technologies. We designed, fabricated, and tested magnetic microactuators. The theoretical results show that the fabricated microactuators can produce the force necessary to remove an adherent cellular layer grown over the actuator surface. By integrating the microactuators into the catheters, we hope to produce an improved catheter with the ability to actively combat the health-threatening occlusion process.
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Affiliation(s)
- Selene A Lee
- NeuroEng. Training Program, School of Medicine, Electrical Engineering Department, Univ. of CA, Los Angeles, CA 90095, USA
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Ellis MJ, Kazina CJ, Del Bigio MR, McDonald PJ. Treatment of recurrent ventriculoperitoneal shunt failure associated with persistent cerebrospinal fluid eosinophilia and latex allergy by use of an "extracted" shunt. J Neurosurg Pediatr 2008; 1:237-9. [PMID: 18352769 DOI: 10.3171/ped/2008/1/3/237] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Shunt failure is commonly associated with infection or mechanical obstruction of the shunt system. The presence of eosinophilia in the cerebrospinal fluid (CSF) has been associated with CSF shunt failure and may be related to both latex and shunt allergies. The authors describe the case of a child with a latex allergy who presented with 10 episodes of shunt failure over a period of 93 months. Cerebrospinal fluid sampling demonstrated persistent eosinophilia (3-36%) and negative cultures. Pathological examination of the ventricular catheter on 3 occasions demonstrated mechanical obstruction by inflammatory debris consisting largely of eosinophils and multinucleated giant cells. On the suspicion that the child might have some uncharacterized allergy to the shunt hardware, shunt replacement was performed using an "extracted" shunt system. The child has remained free of shunt malfunction for > 2 years since the last surgery. Immune responses to unpolymerized silicone are discussed.
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Affiliation(s)
- Michael J Ellis
- Section of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Lee SA, Pinney JR, Khialeeva E, Bergsneider M, Judy JW. Functional evaluation of magnetic microactuators for removing biological accumulation: an in vitro study. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2008; 2008:947-950. [PMID: 19162814 DOI: 10.1109/iembs.2008.4649311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Here we demonstrate the functional capability of microfabricated magnetic actuators in clearing biological accumulation on a model catheter pore. Cell-clearing performance was quantitatively measured by comparing the effect of actuation on the cell density of aggressively growing adherent murine cells. Devices were actuated at a frequency of 100 Hz and a magnetic field of 17.8 kA/m for 30, 45, or 60 min. On average, microactuators removed 37.4% of the adherent cells. The results also revealed that the cell-clearing capability of the microactuator increased as a function of the actuation duration and angle of deflection.
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Affiliation(s)
- Selene A Lee
- NeuroEngineering Training Program, University of California, Los Angeles, Los Angeles, CA 90095 USA
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Hussain NS, Wang PP, James C, Carson BS, Avellino AM. Distal ventriculoperitoneal shunt failure caused by silicone allergy. J Neurosurg 2005; 102:536-9. [PMID: 15796391 DOI: 10.3171/jns.2005.102.3.0536] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓ The placement of a ventriculoperitoneal (VP) shunt is the most common form of treatment for hydrocephalus. Although allergic reactions to the silicone in shunt hardware are very rare, the authors describe a case of silicone allergy causing multiple ventricular shunt revisions. A 24-year-old man, who had undergone multiple VP shunt revisions, presented with shunt malfunction caused by allergic reaction of the tissues surrounding the shunt tubing. The patient's existing silicone-based shunt was replaced with a new polyurethane system, including the proximal and distal catheters as well as the valve mechanism. Contrary to recommendations in previous studies of silicone shunt allergies, long-term immunosuppression was not initiated. The patient was followed up for more than 8 years without recurrence of an allergic reaction to the shunt. This outcome indicates that replacing the original silicone-based shunt system with a polyurethane-based system alone is sufficient in the treatment of a silicone shunt allergy.
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Affiliation(s)
- Namath S Hussain
- Department of Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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VandeVord PJ, Gupta N, Wilson RB, Vinuya RZ, Schaefer CJ, Canady AI, Wooley PH. Immune reactions associated with silicone-based ventriculo-peritoneal shunt malfunctions in children. Biomaterials 2004; 25:3853-60. [PMID: 15020161 DOI: 10.1016/j.biomaterials.2003.10.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2003] [Accepted: 09/25/2003] [Indexed: 10/26/2022]
Abstract
The implantation of ventriculo-peritoneal (VP) shunting systems is the most commonly performed neurological procedure in children with hydrocephalus. Although the overall complication risk is low, the cumulative risk of shunt failure is high and unfortunately results in a high prevalence of revision surgeries. In this study, we explored the concept that some pediatric patients may develop an immune response to either the proteins attached to the silicone implant surface or to the biomaterial itself, and that this reaction may contribute to VP shunt failure in some individuals. The data displays that the sterile shunt malfunction group had a higher rate of protein deposition and increased levels of autoantibodies to the extracted surface proteins as compared to individuals with functioning shunting systems. The precise nature of the shunt-bound proteins that serve as antigens in this experiment have not yet been determined. The data also indicated that some individuals develop antibodies to polymeric substances that cross-react with partially polymerized acrylamide. The detection of significant amounts of shunt-bound protein, antibody responses to these proteins and to polymeric substances suggest that an immunological response to these proteins may play a role in the mechanism behind sterile shunt malfunctions.
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Affiliation(s)
- Pamela J VandeVord
- Departments of Pediatric Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48201, USA.
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Hashimoto M, Yokota A, Urasaki E, Tsujigami S, Shimono M. A case of abdominal CSF pseudocyst associated with silicone allergy. Childs Nerv Syst 2004; 20:761-4. [PMID: 14999512 DOI: 10.1007/s00381-003-0904-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2003] [Indexed: 11/28/2022]
Abstract
CASE REPORT The authors present a case of a patient with an abdominal CSF pseudocyst that resulted from an allergic reaction to silicone. The patient underwent repair surgery of the meningomyelocele associated with the Chiari II malformation, and the V-P shunt was instituted at 6 months of age. A formation of the abdominal CSF pseudocyst and the consequent shunt malfunction were observed 40 days after the V-P shunt. An increase in the number of the peripheral eosinophils and serum immunoglobulin E (IgE), and an infiltration of eosinophils in the specimen harvested from the pseudocyst wall suggested an allergic reaction as the cause of the pseudocyst. A sixth operation to revise the V-P shunt was performed using the shunt system made of "extracted silicone", which was produced extracting the allergic substances. OUTCOME The serum IgE was normalized after surgery and the abdominal CSF pseudocyst has not recurred for 22 months.
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Affiliation(s)
- Masanori Hashimoto
- Department of Neurosurgery, University of Occupational and Environmental Health, Iseigaoka 1-1, 807-8555 Yahata-Nishi, Kitakyushu, Japan.
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Sgouros S, Dipple SJ. An investigation of structural degradation of cerebrospinal fluid shunt valves performed using scanning electron microscopy and energy-dispersive x-ray microanalysis. J Neurosurg 2004; 100:534-40. [PMID: 15035291 DOI: 10.3171/jns.2004.100.3.0534] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Surveys of cerebrospinal fluid (CSF) shunts that have been removed from patients have shown that even when the ventricular catheter is the cause of the obstruction, the valve may be obstructed or underperforming. The aim of this pilot study was to investigate the degradation of shunt valve structure over time due to the deposition of debris. The findings were compared with findings in unused valves. METHODS Scanning electron microscopy was used to visualize the structures of the valves. The items that were examined included two unused and nine explanted cylindrical medium pressure valves, one unused and six explanted Delta 1.5 valves (PS Medical, Goleta, CA), and one explanted Medos Programmable valve (Codman Johnson & Johnson, LeLocle, Switzerland). The valves were cut open, disassembled, and coated in gold. The areas that were analyzed included the main valve chamber, the diaphragm unit, and the antisiphon device. For areas with abnormal deposits, energy-dispersive x-ray microanalysis was performed to establish the chemical composition of the deposits. The reference unused valves had smooth surfaces with no deposits in any areas. All explanted valves had extensive deposits in all surveyed areas. The deposits varied from small clusters of crystals to large areas that displayed a cobblestone appearance. In diaphragm valves the deposits extensively affected the surface of the diaphragm and the gap between the diaphragm and the surrounding case, where normally CSF flows; in the Medos valve the deposits affected in the spring and "staircase" unit. Deposits were present as early as 2 weeks after implantation. On some valves there was a complete film covering the entire outlet of the valve, which formed a cast inside the valve stretching from wall to wall. The deposits consisted mostly of sodium and chloride, but occasionally contained calcium. In all infected and some noninfected valves there was a significant peak of carbon, indicating the presence of protein deposits. CONCLUSIONS It appears that the continuous flow of CSF through shunt valves causes surface deposits of sodium chloride and other crystals on all aspects of the valve, including the outlet pathways. The formation of deposits may be encouraged by the adhesive properties of the materials that constitute the valve parts.
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Affiliation(s)
- Spyros Sgouros
- Department of Neurosurgery, Birmingham Children's Hospital, United Kingdom.
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Govender ST, Nathoo N, van Dellen JR. Evaluation of an antibiotic-impregnated shunt system for the treatment of hydrocephalus. J Neurosurg 2003; 99:831-9. [PMID: 14609161 DOI: 10.3171/jns.2003.99.5.0831] [Citation(s) in RCA: 144] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. Staphylococcus species are the most common organisms responsible for infection following implantable cerebrospinal fluid (CSF) diversionary procedures. The role of an antibiotic-impregnated shunt (AIS) system in the prevention of shunt infection has remained unclear because no human clinical trial has been reported on thus far. In this study, the authors assess an AIS system with respect to its prevention of shunt infection.
Methods. Patients were prospectively randomized into groups to evaluate the efficacy of an AIS system against an identical control shunt system. The data accrued were subjected to a detailed statistical analysis. Logistic regression analysis was performed to determine the independent association between outcome and predictor variables. Shunt function analysis was also performed to compare the average time to infection between the two groups.
One hundred ten patients were recruited; 60 received control shunt systems and 50 received AIS systems. Thirteen shunt infections were recorded (10 in the control group and three in the AIS group). Nine (69%) of 13 infections occurred within 2 months after shunt implantation (eight of 10 in the control group and one of three in the AIS group). Apart from one patient in whom no organism was identified, a total of 14 organisms (12 patients) were cultured from either the CSF (nine) or the shunt apparatus (three). Staphylococcus species accounted for the majority of shunt infections (83%): all 10 control shunts were found to have a positive culture of staphylococci, whereas none of the AISs had any staphylococci (p = 0.038).
Conclusions. The AIS afforded antistaphylococcal protection, especially during the early postoperative period when most shunt infections are known to occur and throughout the follow-up period (median 9 months). The AIS system represents another important tool to enable the neurosurgeon to prevent shunt infections.
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Affiliation(s)
- Soma T Govender
- Department of Neurosurgery, Wentworth Hospital, Nelson R. Mandela School of Medicine, University of Natal, Durban, South Africa
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Kehler U, Klöhn A, Heese O, Gliemroth J. Hydrocephalus therapy: reduction of shunt occlusions using a peel-away sheath. Clin Neurol Neurosurg 2003; 105:253-5. [PMID: 12954541 DOI: 10.1016/s0303-8467(03)00041-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In order to avoid shunt occlusions through particles of brain parenchyma a new procedure was used. Conventionally during ventricle puncture brain tissue may intrude into perforating holes of the ventricular catheter and subsequently shunt dysfunction may occur. By using a peel-away sheath the ventricular catheter can be protected during puncture. The conventional technique (n=90) was compared with the peel-away sheath technique (n=20) in a retrospective analyses in regard to shunt revisions during a 1-year period. Shunt revision was done in 18% (16/90) within 1 year using the conventional technique, respectively, 5% (1/20) using the peel-away sheath technique. Although criteria for statistical significance were not reached these data are worth to be mentioned. A randomised prospective study is initiated and the key features are presented.
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Affiliation(s)
- Uwe Kehler
- Neurosurgical Department, University Hospital Hamburg Eppendorf, 20246, Hamburg, Germany.
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Hanlo PW, Cinalli G, Vandertop WP, Faber JAJ, Bøgeskov L, Børgesen SE, Boschert J, Chumas P, Eder H, Pople IK, Serlo W, Vitzthum E. Treatment of hydrocephalus determined by the European Orbis Sigma Valve II survey: a multicenter prospective 5-year shunt survival study in children and adults in whom a flow-regulating shunt was used. J Neurosurg 2003; 99:52-7. [PMID: 12854744 DOI: 10.3171/jns.2003.99.1.0052] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The goal of this study was to evaluate the long-term results of a flow-regulating shunt (Orbis Sigma Valve [OSV] II Smart Valve System; Integra NeuroSciences, Sophia Antipolis, France) in the treatment of hydrocephalus, whether it was a first insertion procedure or surgical revision of another type of shunt, in everyday clinical practice in a multicenter prospective study. METHODS Patients of any age who had hydrocephalus underwent implantation of an OSV II system. The primary end point of the study was defined as any shunt-related surgery. The secondary end point was a mechanical complication (shunt obstruction, overdrainage, catheter misplacement, migration, or disconnection) or infection. The overall 5-year shunt survival rates and survival as it applied to different patient subgroups were assessed. Five hundred fifty-seven patients (48% of whom were adults and 52% of whom were children) were selected for OSV II shunt implantation; 196 patients reached the primary end point. Shunt obstruction occurred in 75 patients (13.5%), overdrainage in 10 patients (1.8%), and infection in 46 patients (8.2%). The probability of having experienced a shunt failure-free interval at 1 year was 71% and at 2 years it was 67%; thereafter the probability remained quite stable in following years (62% at the 5-year follow-up examination). No difference in shunt survival was observed between the overall pediatric (< or = 16 years of age) and adult populations. In the pediatric age group, however, there was a significantly lower rate of shunt survival in children younger than 6 months of age (55% at the 5-year follow-up examination). CONCLUSIONS In this prospective study the authors demonstrate the effectiveness of flow regulation in the treatment of hydrocephalus both in children and in adults. Flow-regulating shunts limit the incidence of overdrainage and shunt-related complications. The overall 5-year shunt survival rate (62%) compares favorably with rates cited in other recently published series.
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Affiliation(s)
- Patrick W Hanlo
- Department of Neurosurgery, Utrecht University Medical Center, Wilhelmina's Children's Hospital, Utrecht, The Netherlands.
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Coffey RJ, Burchiel K. Inflammatory Mass Lesions Associated with Intrathecal Drug Infusion Catheters: Report and Observations on 41 Patients. Neurosurgery 2002. [DOI: 10.1227/00006123-200201000-00014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Coffey RJ, Burchiel K. Inflammatory mass lesions associated with intrathecal drug infusion catheters: report and observations on 41 patients. Neurosurgery 2002; 50:78-86; discussion 86-7. [PMID: 11844237 DOI: 10.1097/00006123-200201000-00014] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2001] [Accepted: 08/16/2001] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Several reports have described inflammatory mass lesions at the tip of intraspinal drug administration catheters. We evaluated the number of patients reported with this condition and whether data support hypotheses that have been put forth regarding the cause of these lesions. METHODS Information that was reported in the medical literature, and by Medtronic, Inc., to the United States Food and Drug Administration as of November 30, 2000, was reviewed. RESULTS Forty-one cases were identified, including 16 from the literature and 25 that were not published previously in the literature. Because of voluntary reporting and other methodological limitations, the actual number of cases must be higher than reported. All of the patients had chronic pain. The mean duration of therapy was 24.5 months. Most masses were located in the thoracic region. Intrathecal drugs included morphine or hydromorphone, either alone or mixed with other drugs, in 39 of 41 cases. No masses were reported in patients who received baclofen as the only intrathecal medication. Thirty patients underwent surgery to relieve spinal cord or cauda equina compression. Eleven patients were nonambulatory at last follow-up, and one died of a pulmonary embolus. Surgical specimens revealed noninfectious chronic inflammation, granuloma formation, and fibrosis or necrosis. DISCUSSION The most plausible hypothesis with regard to the cause of intrathecal catheter tip mass lesions implicates the administration of relatively high-concentration or high-dose opiate drugs or the use of drugs and admixtures that are not labeled for intrathecal use. CONCLUSION Patients who require high-dose intraspinal opioid therapy and those who receive drugs or admixtures that are not approved for intrathecal use should be monitored closely for signs of an extra-axial mass or catheter malfunction. Prompt diagnosis and treatment may preserve neurological function.
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Anderson SR, Orbegozo M, Racz G, Raj PP. Intrathecal Granuloma in Patients Receiving High-dose Intrathecal Morphine Therapy: A Report of Two Cases. Pain Pract 2001; 1:61-7. [PMID: 17129285 DOI: 10.1046/j.1533-2500.2001.01008.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- S R Anderson
- Texas Tech University Health Sciences Center, Lubbock, Texas 79430, USA
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46
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Anderson SR, Orbegozo M, Racz G, Raj PP. Intrathecal Granuloma in Patients Receiving High‐dose Intrathecal Morphine Therapy: A Report of Two Cases. Pain Pract 2001. [DOI: 10.1111/j.1533-2500.2001.01008.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Gabor Racz
- Texas Tech University Health Sciences Center, Lubbock, Texas
| | - P. Prithvi Raj
- Texas Tech University Health Sciences Center, Lubbock, Texas
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Lam KW, Drake JM, Cobbold RS. Noninvasive cerebrospinal fluid shunt flow measurement by Doppler ultrasound using ultrasonically excited bubbles: a feasibility study. ULTRASOUND IN MEDICINE & BIOLOGY 1999; 25:371-389. [PMID: 10374981 DOI: 10.1016/s0301-5629(98)00164-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Because normal cerebrospinal fluid (CSF) has almost no natural Doppler scatterers, patency testing of ventriculoperitoneal cerebrospinal fluid shunts (small silastic tubing with lumen diameter of approximately 1 mm draining excessive CSF from the brain) cannot be performed by Doppler ultrasound. We have developed a low-frequency bubble excitation system that generates microbubble scatterers in both distilled water and CSF. Doppler ultrasound can then be used for flow measurement in a ventriculoperitoneal shunt. By using low duty-cycle (approximately 10%), low-frequency (approximately 30 kHz), and low-amplitude (approximately 30 kPa) ultrasound, a population of microbubbles can be maintained for sufficiently long times (>10 min) for Doppler ultrasound measurement, although bubble initiation is inconsistent. The minimum pressure needed for bubble maintenance was found to decrease with increasing burst length and duty cycle. It has been possible to detect the presence of CSF shunt flow down to a mean flow rate of 3 mL/h (mean velocity approximately 0.6 mm/s). The bubble maintenance scheme developed satisfies the safety parameters specified by the American Institute of Ultrasound in Medicine (AIUM) and the US Food and Drug Administration (FDA). Results from both in vitro and in vivo (externalized shunts) experiments indicate the feasibility of this scheme for determining realistic CSF shunt flows, though some practical problems remain before the technique will be ready for clinical use.
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Affiliation(s)
- K W Lam
- Institute of Biomedical Engineering, University of Toronto, Ontario, Canada
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Lundberg F, Li DQ, Falkenback D, Lea T, Siesjö P, Söderström S, Kudryk BJ, Tegenfeldt JO, Nomura S, Ljungh A. Presence of vitronectin and activated complement factor C9 on ventriculoperitoneal shunts and temporary ventricular drainage catheters. J Neurosurg 1999; 90:101-8. [PMID: 10413162 DOI: 10.3171/jns.1999.90.1.0101] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The pathogenesis of cerebrospinal fluid (CSF) shunt infection is characterized by staphylococcal adhesion to the polymeric surface of the shunt catheter. Proteins from the CSF--fibronectin, vitronectin, and fibrinogen--are adsorbed to the surface of the catheter immediately after insertion. These proteins can interfere with the biological systems of the host and mediate staphylococcal adhesion to the surface of the catheter. In the present study, the presence of fibronectin, vitronectin, and fibrinogen on CSF shunts and temporary ventricular drainage catheters is shown. The presence of fragments of fibrinogen is also examined. METHODS The authors used the following methods: binding radiolabeled antibodies to the catheter surface, immunoblotting of catheter eluates, and scanning force microscopy of immunogold bound to the catheter surface. The immunoblot showed that vitronectin was adsorbed in its native form and that fibronectin was degraded into small fragments. Furthermore, the study demonstrated that the level of vitronectin in CSF increased in patients with an impaired CSF-blood barrier. To study complement activation, an antibody that recognizes the neoepitope of activated complement factor C9 was used. The presence of activated complement factor C9 was shown on both temporary catheters and shunts. CONCLUSIONS Activation of complement close to the surface of an inserted catheter could contribute to the pathogenesis of CSF shunt infection.
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Affiliation(s)
- F Lundberg
- Department of Infectious Diseases and Medical Microbiology, Lund University, Sweden
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Boch AL, Hermelin E, Sainte-Rose C, Sgouros S. Mechanical dysfunction of ventriculoperitoneal shunts caused by calcification of the silicone rubber catheter. J Neurosurg 1998; 88:975-82. [PMID: 9609291 DOI: 10.3171/jns.1998.88.6.0975] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECT The authors studied new and calcified shunt catheters to identify the prevalence of failures caused by aging materials in the shunt. Complications associated with these devices have various origins. Among late complications, fracture or migration of the system is related to the subcutaneous adhesion of the distal tubing in a growing child. A review of a cohort of 64 children who underwent shunt placement in 1980 with barium-impregnated distal catheters showed that 10 of these patients underwent reoperation for complications related to aging of the shunt material. This group represents 15% of the whole series and 30% of those children who were followed for more than 3 years. The true impact of aging of materials on shunt function is probably underestimated. METHODS The authors performed physical, chemical, and mechanical analyses of the retrieved aged catheters and also of new catheters, resulting in the following findings: 1) calcifications were observed only on the external surface of the catheter, predominantly in its subcutaneous segment at the level of the neck and anterior chest wall; 2) calcifications contained particles of free silicon and barium sulfate, signifying fragmentation of the polymer; 3) the microstructure of the silicone polymer was modified: microfractures and alteration of the polymeric network were observed; 4) silanol groups were observed on the external surface of the catheter; and 5) the mechanical properties of the silicone rubber were degraded, and the aged catheters were more brittle than the new ones, with ruptures at elongations and fracture energy much lower than that seen in new catheters. Furthermore, in vitro testing with a metastable solution of simulated body fluid demonstrated the critical impact of pH variations in liquid media and surface degradation of the catheters on the precipitation of hydroxylapatite crystals. CONCLUSIONS Although most shunt complications can be addressed by better patient management and surgical technique, late complications appear to be partly related to aging of the material. Distal tubing calcifications have been observed in barium-impregnated catheters. The industry recently responded to these observations by introducing plain silicone-coated shunt tubing; further evaluation will show what improvement can be expected.
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Affiliation(s)
- A L Boch
- Service de Neurochirurgie, Hôpital Necker-Enfants Malades, Paris, France
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50
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Cabbell KL, Taren JA, Sagher O. Spinal cord compression by catheter granulomas in high-dose intrathecal morphine therapy: case report. Neurosurgery 1998; 42:1176-80; discussion 1180-1. [PMID: 9588567 DOI: 10.1097/00006123-199805000-00142] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE AND IMPORTANCE The use of chronic intrathecal morphine for the treatment of intractable, nonmalignant pain is becoming more prevalent. A rare but devastating complication of this therapy is the development of spinal cord compression secondary to the formation of intrathecal granulomas. CLINICAL PRESENTATION We report three cases of intrathecal granuloma formation in the thoracic subarachnoid space, associated with intrathecal morphine pumps. These three patients were receiving high doses of morphine to control their pain (25 mg/d, 28 mg/d, and 45 mg/d, respectively) when they presented with signs and symptoms of thoracic spinal cord compression. Myelography and postmyelographic computed tomography of the spine revealed masses causing spinal cord compression. INTERVENTION Two patients underwent thoracic laminectomies for resection of these masses, and the other patient had the intrathecal catheter removed. A pathological examination revealed sterile granulomas in the resected masses. CONCLUSION Intrathecal granulomas are likely to occur with increasing frequency as the use of chronic intrathecal morphine delivery increases in patients with nonmalignant pain. The cause of intrathecal granulomas is unknown, although it is likely that morphine plays a major role in their formation. We think that those patients receiving high doses of morphine are at greater risk for developing this complication.
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Affiliation(s)
- K L Cabbell
- Department of Surgery, University of Michigan Medical Center, Ann Arbor 48109-0338, USA
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