Have we made progress in preventing shunt failure? A critical analysis

Change in Optic Nerve Sheath Diameter and Cerebral Ventricular Shunt Failure in Children

Importance

Ocular point-of-care ultrasonography (POCUS) may be a clinically useful method to evaluate shunt dysfunction for children with hydrocephalus presenting to the emergency department (ED).

Objective

To evaluate whether a change in the optic nerve sheath diameter (ONSD) from prior asymptomatic baseline was associated with shunt failure.

Design, Setting, and Participants

Participants in this prospective single-center observational cohort study at a tertiary care children's hospital were enrolled from January 5, 2018, to March 2, 2022. Children 18 years or younger with cerebrospinal fluid (CSF) shunts were consecutively recruited during routine asymptomatic visits in the outpatient neurosurgery clinic. The institution sees approximately 1000 children with shunts. Children with comorbid eye pathologic conditions known to increase the ONSD were excluded, as were those with shunt interventions between baseline and symptomatic ocular POCUS. Data analysis was completed in May 2024.

Exposures

Baseline ocular POCUS was performed on asymptomatic children with CSF shunts recruited in the outpatient neurosurgery clinic; a second ocular POCUS was performed if the patient subsequently presented to the ED with symptoms of shunt failure. Change in ONSD from prior asymptomatic baseline to symptomatic presentation was the main study exposure.

Main Outcomes and Measures

Shunt failure was defined as intraoperative confirmation of inadequate CSF flow through the shunt system associated with identifiable shunt complications, including catheter or valve obstruction, shunt tubing fracture or disconnection, or proximal catheter migration out of the ventricle within 96 hours from presentation to the ED.

Results

Seventy-six pairs of baseline and symptomatic ultrasonograms from 58 patients (mean [SD] age, 6.6 [4.7] years; 36 of 58 boys [62%]) were included. Twenty patients (35%) had 2 or more prior shunt revisions, and 29 (50%) had communicating hydrocephalus. The primary outcome of intraoperatively confirmed shunt failure was observed in 14 of 76 ED patient presentations (18%). The mean (SD) change in ONSD among patients with shunt failure was 0.89 (0.66) mm vs 0.16 (0.40) mm among patients without shunt failure (mean difference, 0.73 mm [95% CI, 0.47-0.99 mm]; P < .001). The odds of full shunt failure were 1.4 times higher (95% CI, 1.21-1.78; P < .001) for every 0.1-mm increase in ONSD. The area under the receiver operating characteristic curve was 0.86, with an optimal cutoff of 0.4 mm or more, yielding a sensitivity of 0.93, specificity of 0.73, positive predictive value of 0.43, and negative predictive value of 0.98, for a disease prevalence of 15%, with a positive likelihood ratio of 3.39 and negative likelihood ratio of 0.10.

Conclusions and Relevance

In this single-center, prospective cohort study of symptomatic children with CSF shunts, a change in ONSD measured by ocular POCUS was associated with shunt failure. A change in ONSD from prior asymptomatic baseline to symptomatic presentation of less than 0.4 mm identified a population at low risk of true shunt failure. Further research is warranted to validate these findings, the presented change in ONSD threshold, and to risk stratify low-risk patients for cross-sectional neuroimaging.

Treatments for obstructive hydrocephalus secondary to malignant midline intracranial tumors during the perioperative period - a retrospective study of 372 pediatric patients from a single institution

OBJECTIVE

Common treatments for obstructive hydrocephalus caused by malignant midline intracranial tumors during the perioperative period include ventriculoperitoneal shunt (VPS) placement, endoscopic third ventriculostomy (ETV), and direct tumor resection. The purpose of this study is to determine whether it is necessary to treat hydrocephalus before tumor resection and to clarify which treatment is most effective.

METHODS

Data from 372 pediatric patients (under 18 years) with obstructive hydrocephalus due to malignant midline intracranial tumors, referred to the Department of Pediatric Neurosurgery at Beijing Tiantan Hospital between January 2018 and September 2019, were collected. Their clinical features and outcomes were analyzed statistically.

RESULTS

A total of 372 pediatric patients were treated for obstructive hydrocephalus. Of these, 215 patients underwent preoperative VPS placement; the success rate of preoperative VPS placement was 98.1% (211/215), with a mean recurrence duration of 63.5 ± 15.7 days. Forty patients underwent preoperative ETV; the success rate of preoperative ETV was 90.0% (36/40), with a mean recurrence duration of 53.8 ± 44.9 days. In total, 117 patients underwent direct tumor resection; the recurrence rate of hydrocephalus post-resection was 20.5% (24/117), with a mean recurrence duration of 125.0 ± 170.8 days. The recurrence rate of hydrocephalus in patients who required re-shunting after VPS placement was significantly lower than that in patients requiring re-shunting after ETV (p = 0.013).

CONCLUSION

Malignant midline intracranial tumors in pediatric patients often lead to obstructive hydrocephalus, and preoperative interventions, such as VPS placement, are more effective in reducing recurrence rates compared to direct tumor resection. VPS and ETV are both safe and effective treatments, with VPS showing a lower recurrence rate. The findings are primarily applicable to suprasellar, pineal, and fourth ventricular tumors, and further research is needed to explore hydrocephalus management in other midline tumor locations.

Same-day discharge after intracranial shunt revision: a retrospective propensity-matched safety analysis

OBJECTIVE

Patients are often observed overnight after ventricular shunt revision for hydrocephalus. We believe that a same-day discharge after a shunt revision is safe in the appropriate population. The purpose of this study was to determine the appropriate patient population and the safety profile for a same-day discharge following a ventricular shunt revision.

METHODS

We conducted a retrospective chart review of all shunt revisions at a single center from 2014 to 2021. We compared rates of emergency department visits, hospitalization, and revision at 30 and 90 days between same-day discharge and control patients following shunt revision. Non-parametric, logistic regression, and chi-squared testing were performed to measure statistical significance with and without propensity score matching.

RESULTS

A total of 996 patients were examined, with 56 (5.6%) patients being discharged on the same day as the surgery. Patients with a same-day discharge were older, more likely to have distal shunt failure, more likely to have undergone scheduled surgery, and less likely to have visited the emergency department in the prior 30 days. Propensity score matching compared 29 revisions in each group; all covariates were non-significant (p > 0.05), and 30-day and 90-day outcomes were not significantly different the between same-day and non-same day discharge.

CONCLUSIONS

These findings validate the safety profile for the same-day discharge in post-operative shunt patients and describe our patient cohort's preferred characteristics. Scheduled, distal shunt failure patients are preferred for early discharge post-operatively. When validated by further studies, this would provide improved patient comfort and decreased healthcare expenses for a shunt failure.

Current Trends in the Treatment of Pediatric Hydrocephalus: A Narrative Review Centered on the Indications, Safety, Efficacy, and Long-Term Outcomes of Available Treatment Modalities

The pathophysiologic substrate of pediatric hydrocephalus has not been thoroughly elucidated. Valve-based shunt systems have constituted the main therapeutic option since the late 1950s. The initially used systems were concerning the ventricular system and the atrium. In the 1970s, VA shunts were not the main stay of treatment as the preferred option for the terminal end of the drainage system was the peritoneum. Our review analyzes these valve types and attempts a comparison, based on their functional characteristics. Nowadays, the only available surgical alternative for the treatment of hydrocephalus is ETV. This technique is associated with lower infection rates as well as, on average, a lower re-operation rate. Another term that deserves special mention is related to the outcome of ETV in children who had a medical history of previously incorporated shunts and who were subsequently suffering from shunt malfunction. Well-recognized predictive factors associated with secondary ETV failure include age, early onset of hydrocephalus, and prematurity. Although several attempts have been made in order to establish the optimum surgical treatment management in the different subgroups of patientswho are suffering from shunt dysfunction, there is no universal agreement. Therefore, this review attempts to identify the specific subpopulations of patients in whom the insertion of a drainage system as the preferred treatment modality is associated with an optimum long-term prognosis, compared to ETV, and vice versa. The objective of our study is to analyze the safety, efficacy, and outcomes of drainage devices and ETV in pediatric hydrocephalus patients.

Are variations in ventricular catheter placement related to design of the catheter? A single-center cohort study

Background

The use of intracranial catheters is a common procedure used for neurosurgical patients with a variety of pathologies. Despite its frequency of use, shunt failure and revision have been reported to be a common problem. Given that depth of insertion can significantly affect the catheter tip position, a single institution retrospective chart review was performed to examine the accuracy of shunt and external ventricular drain (EVD) placement.

Methods

Computed tomography (CT) images of the head following shunt or ventriculostomy insertion were analyzed to determine the delta between the final length of the intracranial catheter and the intended depth described in the operative notes.

Results

We found that there was a statistically significant difference in the accuracy of placement when comparing EVDs to shunts. The most used EVDs at our institution are marked with a solid black line in increments spaced 2 cm apart. The most used ventricular shunt catheter has a marking at 5 cm and 10 cm from the tip of the catheter. We believe that the visual confirmation that is afforded by metric unit markings on the EVD allows for better final placement of the catheter at the outer table of the calvarium.

Conclusion

The addition of regular millimeter metric unit markings by the manufacturer is imperative in decreasing the chances of error in the insertion of ventricular catheters and preventing potential neurovascular injury to the surrounding structures.

Automated ventricular segmentation and shunt failure detection using convolutional neural networks

While ventricular shunts are the main treatment for adult hydrocephalus, shunt malfunction remains a common problem that can be challenging to diagnose. Computer vision-derived algorithms present a potential solution. We designed a feasibility study to see if such an algorithm could automatically predict ventriculomegaly indicative of shunt failure in a real-life adult hydrocephalus population. We retrospectively identified a consecutive series of adult shunted hydrocephalus patients over an eight-year period. Associated computed tomography scans were extracted and each scan was reviewed by two investigators. A machine learning algorithm was trained to identify the lateral and third ventricles, and then applied to test scans. Results were compared to human performance using Sørensen-Dice coefficients, calculated total ventricular volumes, and ventriculomegaly as documented in the electronic medical record. 5610 axial images from 191 patients were included for final analysis, with 52 segments (13.6% of total data) reserved for testing. Algorithmic performance on the test group averaged a Dice score of 0.809 ± 0.094. Calculated total ventricular volumes did not differ significantly between computer-derived volumes and volumes marked by either the first reviewer or second reviewer (p > 0.05). Algorithm detection of ventriculomegaly was correct in all test cases and this correlated with correct prediction of need for shunt revision in 92.3% of test cases. Though development challenges remain, it is feasible to create automated algorithms that detect ventriculomegaly in adult hydrocephalus shunt malfunction with high reliability and accuracy.

Incidence and Management of Pseudocysts in Patients With Ventriculoperitoneal Shunts: A Study in Pakistan

BACKGROUND

Ventriculoperitoneal (VP) shunts are a common medical intervention used to treat hydrocephalus, a condition characterized by the accumulation of cerebrospinal fluid (CSF) in the brain's ventricles, leading to increased intracranial pressure. While VP shunts are effective in managing hydrocephalus, they can lead to complications such as the formation of abdominal pseudocysts, which can compromise the functionality of the shunt and pose significant health risks.

OBJECTIVE

The primary objective of this study was to determine the incidence of pseudocyst formation in patients with VP shunts in Pakistan. The secondary objective was to evaluate the outcomes of conservative versus surgical management strategies and identify risk factors associated with pseudocyst recurrence in this population.

METHODS

This prospective observational study was conducted at Jinnah Teaching Hospital, Pakistan, from January 2021 to December 2022. The study included 50 patients diagnosed with pseudocysts associated with VP shunts. Participants were managed with either conservative (observation and aspiration) or surgical interventions (shunt revision, relocation, removal, or pseudocyst excision). The primary outcome measures were the resolution rates of pseudocysts and the incidence of complications. Statistical analysis was performed using chi-square tests, t-tests, and Kaplan-Meier survival analysis, with significance set at p<0.05.

RESULTS

The study found a 3.5% incidence of pseudocysts among 1400 VP shunt patients. The median time to pseudocyst formation was 22 months (IQR 18-30). Surgical management yielded an 85% resolution rate compared to 60% for conservative management (p = 0.02). The recurrence of pseudocysts was significantly associated with advanced age (HR 1.8, 95% CI 1.1-3.2), a higher BMI (HR 2.1, 95% CI 1.3-3.7), and the presence of hydrocephalus (HR 1.6, 95% CI 1.2-2.9). Although surgical interventions had a higher complication rate (14% vs. 6% for conservative management), the difference was not statistically significant (p = 0.1).

CONCLUSION

The study highlights a 3.5% incidence of pseudocysts in VP shunt patients, with surgical management proving more effective than conservative methods despite a slightly higher, non-significant risk of complications. These findings underscore the importance of tailored patient management, particularly for those at higher risk of recurrence, and suggest the need for further research to enhance surgical techniques and outcomes, especially in resource-limited settings.

Medical malpractice and cerebrospinal fluid shunts: An analysis of 36 cases

Many physicians, particularly neurosurgeons, face malpractice claims during their career. The aim of this paper is to identify which factors increase the risk of litigation and influence legal outcomes relating to cerebrospinal fluid shunt management. Westlaw, an online legal database, was used to identify all medico-legal cases pertaining to cerebrospinal fluid shunts. Information regarding plaintiff demographics, defendant specialties, reasons for litigation, and trial outcomes were analysed. Thirty-six cases met criteria for inclusion. Most cases returned a defence verdict (44.4%), with delayed treatment or failure to appropriately treat patients with shunts the most common reason for litigation (66.7%). The average plaintiff verdict payout was $4,888,136.75 and average settlement $1,362,307.69. Delay or failure to treat resulted in the largest average payouts for plaintiff verdicts and settlements ($5,329,299.14 and $1,531,500.00, respectively).

Compare the safety and efficacy of endoscopic third ventriculostomy and ventriculoperitoneal shunt placement in infants and children with hydrocephalus: a systematic review and meta-analysis

PURPOSE

Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt placement are two surgical options used for treatment of non-communicating hydrocephalus. The purpose of this study was to compare the efficiency and safety of these techniques in pediatric patients.

MATERIALS AND METHODS

An extensive literature review regarding the clinical outcome, safety and efficiency of ETV and shunting in treatment of hydrocephalus was conducted in Medline, PubMed, Cochrane and Google Scholar databases up to 27 November 2015. Patient demographics, ETV and shunting success and failure rates were extracted.

RESULTS

A total of seven two-arm studies were included for quantitative analysis and 25 single-arm studies were included for systematic review. The two-arm studies recruited a total of 6995 patients: 1046 in the ETV group and 5949 in the shunt group. The pooled results showed that the 1 year success rate of ETV and shunt-placement procedure were similar (pooled RR = 0.870, 95% CI = 0.680-1.112, P = 0.266). The failure rate in the ETV treatment group was 0.9 times higher than in the shunt group; however, the results did not reach statistical significance (pooled RR = 0.893, 95% CI = 0.576-1.383, P = 0.611).

CONCLUSIONS

Both ETV and shunts are associated with similar 1 year success and failure rates. Therefore, there are no current indications to recommend one mode of treatment over the other. Future studies designed to assess the effectiveness of ETV and shunt procedures depending on patient's age and etiology are warranted.

The Top 100 Most Cited Journal Articles on Hydrocephalus

Hydrocephalus represents a significant burden of disease, with more than 383,000 new cases annually worldwide. When the magnitude of this condition is considered, a centralized archive of pertinent literature is of great clinical value. From a neurosurgical standpoint, hydrocephalus is one of the most frequently treated conditions in the field. The focus of this study was to identify the top 100 journal articles specific to hydrocephalus using bibliometric analysis. Using the Journal of Citation Report database, 10 journals were identified. The Web of Science Core Collection was then searched using each journal name and the search term "hydrocephalus." The results were ordered by "Times Cited" and searched by the number of citations. The database contained journal articles from 1976 to 2021, and the following variables were collected for analysis: journal, article type, year of publication, and the number of citations. Journal articles were excluded if they had no relation to hydrocephalus, mostly involved basic science research, or included animal studies. Ten journals were identified using the above criteria, and a catalog of the 100 most cited publications in the hydrocephalus literature was created. Articles were arranged from highest to lowest citation number, with further classification by journal, article type, and publication year. Of the 100 articles referenced, 38 were review articles, 24 were original articles, 15 were comparative studies, 11 were clinical trials, six were multi-center studies, three were cross-sectional, and three were case reports with reviews. Articles were also sorted by study type and further stratified by etiology. If the etiology was not specified, studies were instead subcategorized by treatment type. Etiologies such as aqueductal stenosis, tumors, and other obstructive causes of hydrocephalus were classified as obstructive (n=6). Communicating (n=15) included idiopathic, normal pressure hydrocephalus, and other non-obstructive etiologies. The category "other" (n=3) was assigned to studies that included etiologies, populations, and/or treatments that did not fit into the classifications previously outlined. Through our analysis of highly cited journal articles focusing on different etiologies and the surgical or medical management of hydrocephalus, we hope to elucidate important trends. By establishing the 100 most cited hydrocephalus articles, we contribute one source, stratified for efficient referencing, to facilitate clinical care and future research on hydrocephalus.

Preoperative nomogram predicting ventriculoperitoneal shunt longevity after initial shunt failure

Background and objectives

Initial shunt failure following ventriculoperitoneal (VP) shunt surgery has a significant impact on the working time of the shunt. However, there are few studies regarding factors affecting VP shunt longevity. Hence, in this study, we aimed to build a nomogram to predict the longevity of the replacement VP shunt in patients with initial shunt failure.

Methods

From 2011 to 2021, 142 patients with initial VP failure who underwent VP shunt revision were enrolled and relevant clinical and demographic factors were analyzed. Univariate and multivariate Cox proportional hazard regression models were used to choose predictors, and a nomogram was constructed using nine independent prognostic variables: sex, age, hydrocephalus type, intensive care unit admission, tracheostomy, decompressive craniectomy, craniotomy, lumbar cisterna drainage, and ventricular drainage. The prediction models' discrimination, accuracy, calibration, and clinical value were evaluated using Harrell's C-index, a calibration plot, and decision curve analysis.

Results

At 1 month, 3 months, and 5 years, the nomogram's C-index was 0.680, 0.708, and 0.694, respectively. The nomogram's calibration plot provided a good fit for the overall prediction over the course of 1 year. Decision curve analysis predicted that 1-3 months after surgery will yield good net benefits between 30 and 50% probability thresholds.

Conclusion

A preoperative nomogram may be an effective tool for assessing VP shunt longevity after initial VP shunt placement.

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

OBJECTIVE

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

METHODS AND RESULTS

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

CONCLUSION

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

Safety and efficacy of intracranial vascularized submental lymph node transfer for treating hydrocephalus

Hydrocephalus is routinely treated with ventriculoperitoneal shunt drainage of cerebrospinal fluid (CSF), a procedure plagued by high morbidity and frequent revisions. Vascularized submental lymph node (VSLN) transplants act as lymphatic pumps to drain interstitial fluid (ISF) from lymphedematous extremities. As the field of neuro-lymphatics comes to fruition, we hypothesize the efficacy of VSLN in the drainage of intracranial CSF-ISF. We report novel placement of VSLN in the temporal subdural space in two patients diagnosed with symptomatic communicating hydrocephalus. At a minimum follow-up of 1 month postoperatively, both experienced radiological and clinical improvements.

Cerebrospinal fluid shunt malfunctions: A reflective review

PURPOSE

Pediatric hydrocephalus is a common and challenging condition. To date, the ventriculoperitoneal shunt (VPS) is still the main lifesaving treatment option. Nonetheless, it remains imperfect and is associated with multiple short- and long-term complications. This paper is a reflective review of the current state of the VPS, our knowledge gaps, and the future state of shunts in neurosurgical practice.

METHODS AND RESULTS

The authors' reflections are based on a review of shunts and shunt-related literature.

CONCLUSION

Overall, there is still an urgent need for the neurosurgical community to actively improve current strategies for shunt failures and shunt-related morbidity. The authors emphasize the role of collaborative efforts amongst like-minded clinicians to establish pragmatic approaches to avoid shunt complications.

Developing Predictive Models to Anticipate Shunt Complications in 33,248 Pediatric Patients with Shunted Hydrocephalus Utilizing Machine Learning

INTRODUCTION

Hydrocephalus is a common pediatric neurosurgical pathology, typically treated with a ventricular shunt, yet approximately 30% of patients experience shunt failure within the first year after surgery. As a result, the objective of the present study was to validate a predictive model of pediatric shunt complications with data retrieved from the Healthcare Cost and Utilization Project (HCUP) National Readmissions Database (NRD).

METHODS

The HCUP NRD was queried from 2016 to 2017 for pediatric patients undergoing shunt placement using ICD-10 codes. Comorbidities present upon initial admission resulting in shunt placement, Johns Hopkins Adjusted Clinical Groups (JHACG) frailty-defining criteria, and Major Diagnostic Category (MDC) at admission classifications were obtained. The database was divided into training (n = 19,948), validation (n = 6,650), and testing (n = 6,650) datasets. Multivariable analysis was performed to identify significant predictors of shunt complications which were used to develop logistic regression models. Post hoc receiver operating characteristic (ROC) curves were created.

RESULTS

A total of 33,248 pediatric patients aged 6.9 ± 5.7 years were included. Number of diagnoses during primary admission (OR: 1.05, 95% CI: 1.04-1.07) and initial neurological admission diagnoses (OR: 3.83, 95% CI: 3.33-4.42) positively correlated with shunt complications. Female sex (OR: 0.87, 95% CI: 0.76-0.99) and elective admissions (OR: 0.62, 95% CI: 0.53-0.72) negatively correlated with shunt complications. ROC curve for the regression model utilizing all significant predictors of readmission demonstrated area under the curve of 0.733, suggesting these factors are possible predictors of shunt complications in pediatric hydrocephalus.

CONCLUSION

Efficacious and safe treatment of pediatric hydrocephalus is of paramount importance. Our machine learning algorithm delineated possible variables predictive of shunt complications with good predictive value.

Precise location of the ventricular catheter tip in ventriculoperitoneal shunt placement guided by 3D printed individualized guide

OBJECTIVE

Improper placement of the ventricular catheter tip is the most common cause of shunting disorders after ventriculoperitoneal shunt (VPS) placement surgery. Here, through two illustrative cases, we described a novel method of precise ventricular catheter tip location.

METHODS

Three-dimensional (3D) Slicer software was used to define the ventricle puncture path and determine the ventricle catheter tip location preoperatively, and the 3D individualized guide model was printed.

RESULTS

The ventricular puncture was performed under the guidance of the 3D guide to achieve precise ventricle catheter tip location intraoperatively.

CONCLUSIONS

This technique is safe, simple, efficient and cost-effective, which facilitates its clinical implementation and promotion.

Use of a Prophylactic Retrograde-Flushing Device in High-Risk Pediatric Patients with Ventriculoperitoneal Shunts: A Technical Note

INTRODUCTION

Ventriculoperitoneal shunt (VPS) malfunction rates are as high as 40% in the first year with posthemorrhagic hydrocephalus (PHH) patients having the highest proximal occlusion risk. Debris, protein, and cellular ingrowth most commonly obstruct the proximal ventricular catheter and/or valve. Historically, no preventative methods have demonstrated efficacy. We present a technical note and case series describing the use of a retrograde proximal flushing device and prophylactic flushing protocol to maintain ventricular catheter patency and reduce proximal shunt occlusions.

METHODS

We present our 2.8-4-year follow-up data on the first 9 pediatric cases of ReFlow (Anuncia Inc, Scottsdale, AZ) device implantation combined with routine prophylactic flushing. Rationale for device implantation, patient selection, surgical procedure details, postoperative follow-up, and prophylactic flushing protocol are discussed as well as pre- and postimplantation ventricular catheter obstruction rates. We include a technical note on the device setup and prophylactic flushing protocol.

RESULTS

Patient average age was 5.6 years and all patients had PHH. Minimal follow-up was 2.8 years (range 2.8-4 years). Prophylactic flushing was initiated between 2 and 14 days after ReFlow implantation and has continued as of the last follow-up. In 7 patients, ReFlow implantation occurred during the revision of an existing shunt and in two, implantation was coincident with initial VPS placement. In the 2 years preceding ReFlow and prophylactic flushing, 14 proximal shunt failures occurred in the 7 patients with existing VPS. This was reduced to only one proximal shunt failure in all 9 patients during the full follow-up period after ReFlow and prophylactic flushing.

CONCLUSION

Pediatric VPS placement carries high rates of proximal catheter occlusion, often leading to emergency surgery, morbidity, or even death. The ReFlow device along with routine prophylactic flushing may reduce proximal obstruction and need for revision surgery. Higher patient numbers and longer follow-up periods are necessary to further elucidate the safety and effect of such a device on longer term shunt failures and revision surgery.

Failure of Internal Cerebrospinal Fluid Shunt: A Systematic Review and Meta-Analysis of the Overall Prevalence in Adults

OBJECTIVE

Reported rates of failures of internal cerebrospinal fluid shunt (ICSFS) vary greatly from less than 5% to more than 50% and no meta-analysis to assess the overall prevalence has been performed. We estimated the failure rate after ICSFS insertion and searched for associated factors.

METHODS

Six databases were searched from January 1990 to February 2022. Only original articles reporting the rate of adult shunt failure were included. Random-effects meta-analysis with a generalized linear mixed model method and logit transformation was used to compute the overall failure prevalence. Subgroup analysis and meta-regression were implemented to search for associated factors.

RESULTS

Of 1763 identified articles, 46 were selected, comprising 70,859 ICSFS implantations and 13,603 shunt failures, suggesting an accumulated incidence of 19.2%. However, the calculated pooled prevalence value and its 95% confidence interval (CI) were 22.7% (95% CI, 19.8-5.8). The CI of the different estimates did not overlap, indicating a strong heterogeneity confirmed by a high I² of 97.5% (95% CI, 97.1-97.8; P < 0.001; τ² = 0.3). Ninety-five percent prediction interval of shunt failure prevalence ranged from 8.75% to 47.36%. A meta-regression of prevalence of publication found a barely significant decreasing failure rate of about 2% per year (-2.11; 95% CI, -4.02 to -0.2; P = 0.031).

CONCLUSIONS

Despite being a simple neurosurgical procedure, ICSFS insertion has one of the highest risk of complications, with failure prevalence involving more than 1 patient of 5. Nonetheless, all efforts to lower this high level of shunt failure seem to be effective.

Contactless Ultrasonic Cavitation for the Prevention of Shunt Obstruction in Hydrocephalus: A Proof-of-Concept Study

BACKGROUND

Obstructive failure of implanted shunts is the most common complication in the treatment of hydrocephalus. Biological material and debris accumulate in the inner walls of the valve and catheters block the normal flow of the drained cerebrospinal fluid causing severe symptoms with high morbidity and mortality. Unfortunately, at present, there is no effective preventive protocol or cleaning procedure available.

OBJECTIVE

To assess whether externally applied, focused ultrasound beams can be used to resuspend deposits accumulated in brain shunts safely.

METHODS

A computational model of an implanted brain shunt was implemented to test the initial design parameters of a system comprising several ultrasound transducers. Under laboratory conditions, configurations with 3 and 4 transducers were arranged in a triangle and square pattern with their radiation axis directed towards a target model of the device, 2 catheters and a brain shunt filled with water and deposited graphite powder. The ultrasound beams were then concentrated on the device across a head model.

RESULTS

The computational model revealed that by using only 3 transducers, the acoustic field intensity on the valve was approximately twice that on the brain surface suggesting that acoustic cavitation could be selectively achieved. Resuspension of graphite deposits inside the catheters and the valve were then physically demonstrated and video-recorded with no temperature increase.

CONCLUSION

The technology presented here has the potential to be used routinely as a noninvasive, preventive cleaning procedure to reduce the likelihood of obstruction-related events in patients with hydrocephalus treated with an implanted shunt.

Reliability and feasibility of optic nerve point-of-care ultrasound in pediatric patients with ventricular shunts

PURPOSE

To determine the interrater reliability of optic nerve sheath diameter (ONSD) and optic disc elevation (ODE) via ocular ultrasound by emergency and neurosurgery providers in children with ventricular shunts, and to explore the feasibility of acquiring and measuring images.

METHODS

Two novices who underwent focused training and one expert in ocular ultrasound independently acquired images and measured ONSD and ODE on the same children, 0-18 years with ventricular shunts, blinded to each other's images and measurements. Patient tolerance, image quality, and time-to-complete exams were recorded. Images meeting a priori defined quality metrics were included. Mixed models and bootstrap analysis were used to obtain inter-rater reliability and 95% confidence intervals.

RESULTS

Eighty-one children were enrolled from August 2016 to July 2017, with mean age 9.6 years (SD 5.25, range 5 months-17.7 years). High-quality images (≥ 4 on 7-point quality Likert scale) were obtained in 83% of ONSD assessments and 95% of ODE assessments. The ICC_ONSD was 0.82 (95% CI 0.76-0.91) for right eyes and 0.73 (95% CI 0.69-0.85) for left, while ICC_ODE was 0.81 (95% CI 0.75-0.89) for right eyes and 0.85 (95% CI 0.79-0.91) for left. Mean study duration (both eyes) was 2:52 min (SD 54 s).

CONCLUSION

Clinicians generated high-quality ocular ultrasound images with excellent interrater reliability when acquiring and measuring images of ONSD and ODE in children with ventricular shunts.

Cerebrospinal fluid hydrocephalus shunting: cisterna magna, ventricular frontal, ventricular occipital

Despite advances in cerebrospinal fluid shunting technology, complications remain a significant concern. There are some contradictions about the effectiveness of proximal catheter entry sites that decrease shunt failures. We aim to compare efficiency of shunts with ventricular frontal, ventricular occipital, and cisterna magna entry sites. The systemic search was conducted in the database from conception to February 16, 2022 following guidelines of PRISMA. Between 2860 identified articles, 24 articles including 6094 patients were used for data synthesis. The aggregated results of all patients showed that "overall shunt failure rate per year" in mixed hydrocephalus with ventricular frontal and occipital shunts, and cisterna magna shunt (CMS) were 9.0%, 12.6%, and 30.7%, respectively. The corresponding values for "shunt failure rate" due to obstruction were 15.3%, 31.5%, and 10.2%, respectively. The similar results for "shunt failure rate" due to infection were 11.3%, 9.1%, and 27.2%, respectively. The related values for "shunt failure rate" due to overdrainage were 2.9%, 3.9%, and 13.6%, respectively. CMS was successful in the immediate resolution of clinical symptoms. Shunting through an occipital entry site had a greater likelihood of inaccurate catheter placement and location. Contrary to possible shunt failure due to overdrainage, the failure likelihood due to obstruction and infection in pediatric patients was higher than that of mixed hydrocephalus patients. In both mixed and pediatric hydrocephalus, obstruction and overdrainage were the most and least common complications of ventricular frontal and occipital shunts, respectively. The most and least common complications of mixed CMS were infection and obstruction, respectively.

Hydrocephalus Study Design: Testing New Hypotheses in Clinical Studies and Bench-to-Bedside Research

In this article, we aimed to describe some of the currently most challenging problems in neurosurgical management of hydrocephalus and how these can be reasons for inspiration for and development of research. We chose 4 areas of focus: 2 dedicated to improvement of current treatments (shunt implant surgery and endoscopic hydrocephalus surgery) and 2 dedicated to emerging future treatment principles (molecular mechanisms of cerebrospinal fluid secretion and hydrocephalus genetics).

Synthetic vascular grafts as a new treatment option for space-occupying tumor bed cysts

Introduction

Several authors have reported the formation of slit valves as the underlying pathomechanism of space-occupying tumor bed cysts. Iatrogenic slit valves following the resection of high-grade gliomas have been linked to certain risk factors such as intraoperative opening of the ventricles and attempts to seal these. The best therapeutic management of such cystic lesions remains elusive. Several treatment options such as cyst fenestration or cystoperitoneal shunting have been employed but remain associated with high rates of recurrence. With the given complications of the above-described treatment options, the objective was to devise a new therapy option that is safe and effective and treats the slit valve itself rather than its symptoms.

Methods

Between the years of 2010 and 2020, we successfully treated four patients with high-pressure tumor bed cysts following glioma resection by implantation of synthetic ringed vascular grafts into the slit valve.

Results

Postoperatively, the tumor bed cysts were regressive in all patients. Moreover, none of the treatment patients developed any complications associated with the implanted vascular grafts. Revision-free survival was 10, 12, 53, and 126 months, respectively.

Conclusion

The use of synthetic vascular grafts as a means of stenting slit valves is a safe and effective novel treatment option for high-pressure tumor bed cysts.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-022-05123-y.

Computational Modeling and Simulation to Quantify the Effects of Obstructions on the Performance of Ventricular Catheters Used in Hydrocephalus Treatment

Pediatric hydrocephalus is a debilitating condition that affects an estimated 1-2 in 1000 newborns, and there is no cure. A traditional treatment is surgical insertion of a shunt system which was designed 50 years ago, and minimal ensuing progress has been made in improving the failure rate of these devices resulting in the need for multiple brain surgeries during an affected child's lifetime for shunt replacement. A first step toward decreasing the failure rate is to optimize the ventricular catheter component of the shunt to minimize its propensity for obstruction. Given the many geometric properties and patient specific in vivo conditions needed to characterize the fluid dynamics affecting ventricular catheter performance, validated computational simulation is an efficient method to rapidly explore and evaluate the effects of this large parameter space to inform improved design and to investigate patient specific shunt performance. This chapter provides the details on how to build a computational model of a ventricle and implanted catheter, analyze the fluid dynamics through an obstructed catheter, and postprocess the results to predict catheter performance for varying geometry and in vivo conditions.

Shunt complications and revisions in children: A retrospective single institution study

INTRODUCTION

Shunt surgery in children is associated with high revision and complication rates. We investigated revision rates and postoperative complications to specify current challenges associated with pediatric shunt surgery.

METHODS

All patients aged < 18 years admitted to St. Olavs University Hospital, Norway, from January 2008 through December 2017, who underwent primary shunt insertions, were reviewed. Follow-up ranged from 1 to 10 years. Ventriculoperitoneal, cystoperitoneal, and ventriculoatrial shunts were included. All subsequent shunt revisions and 30-day postoperative complication rates were registered.

RESULTS

81 patients underwent 206 surgeries in the study period. 47 patients (58%) required minimum one revision during follow-up. In 14 (29.8%), the first revision was due to the misplacement of hardware. Proximal occlusion was the most common cause of revision (30.4%), followed by misplacement (18.5%) and infection (9.6%). Young age and MMC were associated with revision surgery in a univariable analysis, but were not significant in multivariable analyses. Congenital hydrocephalus was associated with infection (p = .028). In approximately 30% of procedures, complications occurred within 30 days postoperatively, the most common being revision surgery. In approximately 5% of the procedures, medical complications occurred.

CONCLUSION

Children are prone to high revision and complication rates, and in this study, misplacement of hardware and proximal occlusion were the most common. Complication rates should not be limited to revision rates only, as 30-day complication rates indicate a significant rate of other complications as well. Multi-targeted approaches, perhaps focusing on measures to reduce misplacement, may be key to reducing revision rates.

Determination of Programmable Shunt Setting Using CT: Feasibility Study

BACKGROUND

Programmable shunts can be adjusted to optimize CSF diversion in patients with hydrocephalus without the need for re-operation. Currently, all shunts incorporate radiopaque markers so that their setting can be determined on skull X-ray images. The purpose of this study was to evaluate whether the shunt setting could also be determined ex vivo and in vivo using the data from a standard head CT scan since one is nearly always obtained when patients with VP shunts present with new symptoms that could be due to shunt malfunction.  Materials and Methods: Four commonly used programmable shunts were attached to a dried skull and scanned using a variety of CT techniques. The shunts imaged were the CertasTM Plus (Codman, Raynham, Massachusetts), Polaris® (Sophysa, Orsay, France), proGAV 2.0® (Braun, Bethlehem, Pennsylvania), and Hakim® (Codman, Raynham, Massachusetts). Each shunt was scanned at two different valve settings using multiple CT techniques: CTDIvol 75, 140kVp, 330mAs, CTDIvol60, 120kVp 390mAs, CTDIvol40, 80kVp with 430mAs, 140kVp with 215mAs. Image reconstruction with and without CT metal suppression software was used for all scans, and the data was reconstructed into volume-rendered images. We enlisted ten observers to review the volume-rendered images only. After a short set of training slides viewed by all observers, they were asked to predict the shunt setting for each valve along with their level of confidence. One clinical case of a patient with a programmable valve was evaluated on a CT scan.

RESULTS

 Using the volume-rendered images only, the two shunt settings of the Polaris shunt were correctly predicted by all the observers and in nine of 10 settings for the CertasTM Plus valve. For the Hakim® shunt and the proGAV 2.0® shunt, setting prediction accuracy was 0% and 10%, respectively. In one clinical case, the programmable valve setting could be determined from the CT scan data.

CONCLUSION

 The valve setting of at least two currently available programmable shunts can be determined using volume-rendered images generated from CT data. Reconstructions using metal suppression software were rated as superior and may be necessary for some valve designs.

Choroid Plexectomy for Hydrocephalus Management in a Pediatric Patient with a Pilocytic Astrocytoma

Choroid plexectomy is a debated surgical intervention for the treatment of hydranencephaly and chronic infected hydrocephalus. We present a case of a 2-year-old with multiple shunt revisions and hydrocephalus secondary to a pilocytic astrocytoma. He presented with new somnolence, vomiting, and abdominal distension 5 months post subtotal tumor resection, with a history of shunt revisions and infections related to his chemotherapy-induced low white blood cell count. He underwent choroid plexus coagulation and resection. Three years post choroid plexectomy, the patient continues to meet neurodevelopmental milestones and is shunt independent. While ventricular shunt placement is the most common course of treatment, choroid plexectomy should be considered as an alternative treatment of hydrocephalus secondary to other neurological disorders, especially when the patient is immunocompromised, to avoid the recurrent infections seen with shunt placement.

The Impact of Hydrocephalus Shunt Devices on Quality of Life

BACKGROUND

Despite advances in hydrocephalus shunt technology and improvement in hydrocephalus management, many patients have chronic disability and require multiple surgeries throughout their lifetime. There is limited data from patients' perspective regarding the impact of shunt devices on quality-of-life.

METHODS

A cross-sectional survey was developed to evaluate the impact of shunt devices on patient quality-of-life. The survey was distributed via social media platforms of the Hydrocephalus Association, and patients self-selected to anonymously complete the online questionnaire. A literature review was performed to contextualize the findings from the survey.

RESULTS

A total of 562 survey responses were obtained from a network encompassing 35,000 members. The mean age was 30 years old (0.5-87), and 65% identified as female. Eighty one percent underwent at least 1 shunt revision surgery, with a reported average of 10 shunt revision surgeries per patient (1-200 surgeries). Occlusion, shunt migration and infection were the leading causes for revision at 60%, 47%, and 35%, respectively. In addition, 72% of patients reported pain and discomfort from the device, and 68% expressed avoidance of certain activities due to "fear of bumping shunt." Despite numerous articles discussing shunt technology, a review of the literature indicated a paucity of studies specifically evaluating the burden of shunt devices from a patient/caregiver perspective.

CONCLUSIONS

The findings from this study suggest long-term physical and psychosocial burden associated with shunt devices. Importantly, this study highlights the need for concerted efforts to develop validated tools to study patient reported outcomes as it relates to neurocranial implanted devices.

Effect of Intraoperative Computed Tomography on Ventriculoperitoneal Shunt Survival

BACKGROUND

In patients with hydrocephalus who undergo ventriculoperitoneal shunt placement, the ventricular catheter tip position is one of the most important prognostic factors influencing shunt survival. The aim of this study was to present our findings of ventriculoperitoneal shunt placement performed with intraoperative computed tomography (CT) and to evaluate the effect of intraoperative CT-based image guidance on optimal catheter positioning and overall shunt survival.

METHODS

Of the study enrolled 345 patients with hydrocephalus who underwent ventriculoperitoneal shunt placement for the first time between 2008 and 2018. Ventricular catheters were inserted freehand via the Kocher point into the lateral ventricle in all patients. In 163 patients, intraoperative CT was performed to confirm the tip position. In this group of patients, if the tip position was nonoptimal, the catheter was ejected and reinserted during the surgery. In the remaining 182 patients, the tip position was assessed with routine postoperative CT. The effect of performing intraoperative CT on catheter tip positioning and shunt failure was investigated.

RESULTS

Nonoptimal tip position was significantly correlated with shunt dysfunction even when excluding nonobstructive causes (P < 0.001). In the intraoperative CT group, 11 ventricular catheters (6.7%) were intraoperatively repositioned. The repositioning significantly improved the optimal tip position rate from 54% to 58.3% (P = 0.007). Intraoperative CT usage also showed direct correlation with shunt survival (P = 0.006).

CONCLUSIONS

Intraoperative CT is an effective tool for increasing the rate of optimal tip positioning and thereby overall shunt survival.

Multimodal Sensing Capabilities for the Detection of Shunt Failure

Hydrocephalus is a medical condition characterized by the abnormal accumulation of cerebrospinal fluid (CSF) within the cavities of the brain called ventricles. It frequently follows pediatric and adult congenital malformations, stroke, meningitis, aneurysmal rupture, brain tumors, and traumatic brain injury. CSF diversion devices, or shunts, have become the primary therapy for hydrocephalus treatment for nearly 60 years. However, routine treatment complications associated with a shunt device are infection, obstruction, and over drainage. Although some (regrettably, the minority) patients with shunts can go for years without complications, even those lucky few may potentially experience one shunt malfunction; a shunt complication can require emergency intervention. Here, we present a soft, wireless device that monitors distal terminal fluid flow and transmits measurements to a smartphone via a low-power Bluetooth communication when requested. The proposed multimodal sensing device enabled by flow sensors, for measurements of flow rate and electrodes for measurements of resistance in a fluidic chamber, allows precision measurement of CSF flow rate over a long time and under any circumstances caused by unexpected or abnormal events. A universal design compatible with any modern commercial spinal fluid shunt system would enable the widespread use of this technology.

Impact of Hospital Volume on Outcome After Surgical Treatment for Hydrocephalus: A U.S. Population Study From the National Inpatient Sample

Introduction

Hydrocephalus remains a common condition with significant patient morbidity; however, accurate accounting of the incidence of this disease as well as of the impact of hospital volume on outcome remains limited.

Methods

The National Inpatient Sample was used to evaluate patients who underwent surgical treatment of hydrocephalus from 2009-2013. Patient demographics (e.g., length of stay, disposition, charges), and the impact of hospital volume on outcomes were evaluated.

Results

A total of 156,205 patients were identified. Ventriculoperitoneal (VP) shunting the most common type of device (35.8%) followed by shunt replacement (23.9%). Treatment charges for hydrocephalus were $332 million in 2009 and $418 million in 2013 nationally. High-volume hospitals had more routine discharges compared with lower-volume hospitals (65.7% vs. 50.9%, p<0.0001), which was a trend that improved over time. Multivariate analysis confirmed that hospital volume was independently associated with routine disposition after adjusting for other factors such as patient age, length of stay, and shunt type. However, hospital volume showed a small association with length of stay (β = -0.05, p = 0.0001) and did not impact hospital charges on multivariate analysis.

Conclusion

This analysis provides a recent update of hydrocephalus epidemiology, trends, and outcomes nationally. Estimates from this study suggest that hydrocephalus is a common and costly problem. Hospital volume was for the first time to be associated with important differences in patient outcomes.

Revision and complication rates in adult shunt surgery: a single-institution study

BACKGROUND

CSF diversion with shunt placement is frequently associated with need for later revisions as well as surgical complications. We sought to review revision and complication rates following ventriculoperitoneal, ventriculoatrial and cystoperitoneal shunt placement in adult patients, and to identify potential risk factors for revision surgery and postoperative complications.

METHOD

Included patients were adults (≥ 18 years) who underwent primary shunt insertion at St. Olavs Hospital in Trondheim, Norway, from 2008 through 2017. The electronic medical records and diagnostic imaging from all hospitals in our catchment area were retrospectively reviewed. Follow-up ranged from 1 to 11 years. Complications were graded according to the Landriel Ibañez classification system.

RESULTS

Of the 227 patients included, 47 patients (20.7%) required revision surgery during the follow-up. In total, 90 revision surgeries were performed during follow-up. The most common cause for the first revision was infection (5.7%) and for all revisions proximal occlusion (30.0%). A total of 103 patients (45.4%) experienced ≥ 1 complication(s). Mild to moderate complications (grade I and II) were detected in 35.0% of all procedures. Severe or fatal complications (grade III and IV) were observed in 8.2% of all procedures. Urinary tract infections and pneumonia were common postoperatively (13.9% and 7.3%, respectively), and the most common IIb complication was shunt misplacement (proximally or distally). Two out of fourteen deaths within 30 days were directly associated with surgery. We did not find that aetiology/indication, age or gender influenced the occurrence of revision surgery or a grade III or IV complication.

CONCLUSIONS

Shunt surgery continues to be a challenge both in terms of revision rates and procedure-related complications. However, the prediction of patients at risk remains difficult. A multidimensional focus is probably needed to reduce risks.

An adjustable gravitational valve for initial VP-shunt treatment in hydrocephalic preterm neonates and infants below 1 year of age

OBJECTIVE

Shunt treatment for hydrocephalus in children should aim for sustainable flexibility in regard to optional, perspective pressure level adjustment during advancing physical and mental development. Gravitation-assisted shunt valves are designed to prevent hydrostatic over-drainage frequently observed in the long course of shunt-treated hydrocephalus. We prospectively studied and analyzed the implication, safety, and feasibility for an adjustable gravitational unit combined with a fixed differential-pressure (DP) valve for neonates and infants primary shunted within the first 12 months of life.

METHODS

Clinical course of hydrocephalic neonates and infants who received initial VP-shunt insertion in the early post-natal phase were monitored prospectively on the basis of our digital institutional Hydrocephalus & Shunt Registry. All patients were equipped with a fixed DP valve combined with a programmable gravitational unit activated in upright body position. Patients with a minimum shunt follow-up of 24 months were considered for further statistical analysis regarding hydrocephalus etiology, surgical setting, pre- and post-operative ventricular enlargement, head circumference, valve pressure setting, implication for the adjustment option of the gravitational unit, type and number of shunt complications, and revision-free shunt and valve survival.

RESULTS

Seventy-eight pediatric patients received primary VP-shunt insertion at a mean age of 10 weeks with age gestationally corrected for preterm neonates. Hydrocephalus was related to perinatal IVH (64%), CNS malformation (11%), spina bifida (9%), congenital aqueductal stenosis (9%), and idiopathic (4%) or post-infectious etiology (3%). Fifty-two patients (70%) presented with history of prematurity (gestational age 23-36 weeks). Regular follow-up carried out for a mean period of 63 months demonstrated that ventricular enlargement decreased significantly after applied treatment and excessive head growth could be counteracted effectively. At least one pressure level adjustment was performed in 31% of all patients after 12 months, in 42% after 24 months, and in 64% at the time of last clinical follow-up since initial shunt insertion. Pressure level adjustments were successful in cases of clinical or radiographic signs of under- or over-drainage for individual patients of various ages during entire clinical course. Mean pressure setting for upright position was 24.1 cm H₂O at the time of initial shunt insertion and increased to 26.4 cmH₂O at the time of last clinical follow-up. Revision-free shunt-survival rates after 12 and 24 months were 79% and 70% and valve-survival rates 91% and 90%, respectively.

CONCLUSION

The combination of a fixed DP valve with an adjustable gravitational unit utilized as first-line shunt regimen was feasible and safe in a highly vulnerable subgroup of hydrocephalic infants. The adjustment option for the gravitational unit showed frequent and increasing implication over time and was beneficial even during the very early developmental stage of limited autonomous mobility. To our knowledge this is the first ever reported long-term investigation of an age-consistent pediatric patient collective primary shunted with an adjustable gravitational valve system.

United States emergency department visits for children with cerebrospinal fluid shunts

OBJECTIVE

CSF shunt placement is the primary therapy for hydrocephalus; however, shunt malfunctions remain common and lead to neurological deficits if missed. There is a lack of literature characterizing the epidemiology of children with possible shunt malfunctions presenting to United States emergency departments (EDs).

METHODS

A retrospective study was conducted of the 2006-2017 National Emergency Department Sample. The data were queried using an exhaustive list of Current Procedural Terminology and International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes representing children with hydrocephalus diagnoses, diagnostic imaging for shunt malfunctions, and shunt-related surgical revision procedures.

RESULTS

In 2017, there were an estimated 16,376 ED visits for suspected shunt malfunction. Children were more commonly male (57.9%), ages 0-4 years (42.2%), and publicly insured (55.8%). Many did not undergo diagnostic imaging (37.2%), and of those who did, most underwent head CT scans (43.7%). Between 2006 and 2017, pediatric ED visits for suspected shunt malfunction increased 18% (95% CI 12.1-23.8). The use of MRI increased substantially (178.0%, 95% CI 176.9-179.2). Visits resulting in discharge home from the ED increased by 76.3% (95% CI 73.1-79.4), and those involving no surgical intervention increased by 32.9% (95% CI 29.2-36.6).

CONCLUSIONS

Between 2006 and 2017, ED visits for children to rule out shunt malfunction increased, yet there was a decline in surgical intervention and an increase in discharges home from the ED. Possible contributing factors include improved clinical criteria for shunt evaluation, alternative CSF diversion techniques, changing indications for shunt placement, and increased use of advanced imaging in the ED.

ABBREVIATIONS

CPT = Current Procedural Terminology; ED = emergency department; ETV = endoscopic third ventriculostomy; ICD-9 = International Classification of Diseases, Ninth Revision; ICD-10 = International Classification of Diseases, Tenth Revision; NEDS = National Emergency Department Sample.

Peritonitis caused by Roseomonas mucosa after ventriculoperitoneal shunt revision: a case report

Ventriculoperitoneal shunt (VPS) is an adequate treatment for congenital hydrocephalus or chronic hydrocephalus in adults. Yet, it is a surgery associated with a significant rate of complications amongst neurosurgical procedures, with frequent shunt obstructions and infections. We report the first-ever case of peritonitis caused by Roseomonas mucosa, shortly after the revision of a VPS ventricular catheter. Hardware removal and proper antibiotic therapy led to the patient's recovery. Roseomonas mucosa is an opportunistic skin pathogen with an antibiotic resistance profile to many beta-lactamines and a tropism for indwelling catheters and post-operative period. Nowadays, it should be taken into account in case of infection of indwelling catheters and for some implantable medical devices.

Complications After Dual Placement of a Baclofen Pump and Ventricular Shunt in Individuals With Severe Brain Injury

Objective

To assess the complications of dual placement of an intrathecal baclofen (ITB) pump and a ventriculoperitoneal shunt (VPS) in people with severe brain injury.

Design

Case series.

Setting

Referral center, ambulatory, and hospitalized care.

Participants

Referred sample (N=9) composed of 5 men and 4 women with severe brain injuries (5 traumatic brain injuries, 3 subarachnoid hemorrhages, 1 intracerebral hemorrhage) and a mean disease duration of 6±4.5 years (range, 0.5-11.4y).

Intervention

Both systems (ie, an ITB device and a VPS system) were implanted in all participants.

Main Outcome Measures

We assessed the number and type of complications that occurred after implantation of the second system, as well as subsequent interventions.

Results

The ITB delivery system was implanted after the VPS system in 5 patients (ITB group), and the VPS system was the second implanted system in 4 groups (VPS group). Seven complications occurred in 7 patients after implantation of the second system, 4 in the ITB group and 3 in the VPS group. Three of the complications were drug-related, 2 were procedure-related, and 2 were device-related. The complication occurred within 4 days after implantation of the second system in 6 patients.

Conclusions

Complications are frequent in patients who undergo implantation of both an ITB delivery device and a VPS system. Drug-related complications were more common. Complications occurred more often when an ITB device was implanted as the second system. The critical period is the first 4 days.

Management of paediatric hydrocephalous with Miethke fixed pressure gravitational valves. The Alder Hey Children's Hospital experience

OBJECTIVE

The management of paediatric hydrocephalous remains challenging with the complication and revision rates being consistent in the literature. We hypothesise that the use of a fixed pressure gravitational valve for all de novo shunt insertions decreases the rate of functional revisions and that by implementing the routine use of gravitational valves in children, we would see a reduction in over-drainage and slit ventricle syndrome.

METHODS

Retrospective data collection in a single centre, between February 2010 and August 2018. All patients undergoing fixed pressure gravitational Miethke valve insertion were included. We collected data on patients' demographics, reason for shunt insertion, type of valve and time to and reason for first revision. Data analysis was done with SPSS.

RESULTS

A total of 235 patients were included in our study (124 males, 111 females), aged from 0 to 18.6 years (median 0.28). A total of 99 shunt revisions were documented, 30 of which secondary to ventricular catheter malfunction and 28 secondary to infection. The overall mechanical valve survival rates were 88.5%, 86.4% and 85.5% at 1, 2 and 5 years, respectively. Shunt revision due to over-drainage was documented in only 3 cases (1.3%).

CONCLUSION

Our results are in agreement with existing literature regarding shunt failures secondary to all extrinsic factors to the valve (infection and mechanical failure). We have shown that the use of a Miethke fixed pressure valve for all de novo shunt insertions in paediatric hydrocephalus decreases the need for functional revisions with valve survival rates being superior to the ones described for other types.

A Noninvasive Retrograde Flushing System for Shunted Hydrocephalus: Initial Case Series of 25 Patients

Hydrocephalus is a common neurosurgical pathology associated with high patient morbidity and systemwide healthcare costs. A significant portion of these costs are related to the failure of ventricular shunting systems. Despite decades of research and technological development, the rate of shunt failure and revision has not significantly improved. The Reflow™ Ventricular System (Anuncia, Inc., Lowell, MA) is a recent technological development with the potential to prolong the shunt lifespan. This system introduces a noninvasive means of flushing a shunt proximally with a controlled, repeatable pulse of cerebral spinal fluid (CSF) and of creating a new ventricular opening for occluded shunts. In this multicenter case series, we present the early clinical experiences with this device and discuss its potential.

Ventriculo-peritoneal shunting devices for hydrocephalus

BACKGROUND

Hydrocephalus is a common neurological disorder, caused by a progressive accumulation of cerebrospinal fluid (CSF) within the intracranial space that can lead to increased intracranial pressure, enlargement of the ventricles (ventriculomegaly) and, consequently, to brain damage. Ventriculo-peritoneal shunt systems are the mainstay therapy for this condition, however there are different types of shunt systems.

OBJECTIVES

To compare the effectiveness and adverse effects of conventional and complex shunt devices for CSF diversion in people with hydrocephalus.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (2020 Issue 2); Ovid MEDLINE (1946 to February 2020); Embase (Elsevier) (1974 to February 2020); Latin American and Caribbean Health Science Information Database (LILACS) (1980 to February 2020); ClinicalTrials.gov; and World Health Organization International Clinical Trials Registry Platform.

SELECTION CRITERIA

We selected randomised controlled trials or quasi-randomised trials of different types of ventriculo-peritoneal shunting devices for people with hydrocephalus. Primary outcomes included: treatment failure, adverse events and mortality.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies for selection, assessed risk of bias and extracted data. Due to the scarcity of data, we performed a Synthesis Without Meta-analysis (SWiM) incorporating GRADE for the quality of the evidence.

MAIN RESULTS

We included six studies with 962 participants assessing the effects of standard valves compared to anti-syphon valves, other types of standard valves, self-adjusting CSF flow-regulating valves and external differential programmable pressure valves. All included studies started in a hospital setting and offered ambulatory follow-up. Most studies were conducted in infants or children with hydrocephalus from diverse causes. The certainty of the evidence for most comparisons was low to very low. 1. Standard valve versus anti-syphon valve Three studies with 296 randomised participants were included under this comparison. We are uncertain about the incidence of treatment failure in participants with standard valve and anti-syphon valves (very low certainty of the evidence). The incidence of adverse events may be similar in those with standard valves (range 0 to 1.9%) and anti-syphon valves (range 0 to 2.9%) (low certainty of the evidence). Mortality may be similar in those with standard valves (0%) and anti-syphon valves (0.9%) (RD 0.01%, 95% CI -0.02% to 0.03%, low certainty of the evidence). Ventricular size and head circumference may be similar in those with standard valves and anti-syphon valves (low certainty of the evidence). None of the included studies reported the quality of life of participants. 2. Comparison between different types of standard valves Two studies with 174 randomised participants were included under this comparison. We are uncertain about the incidence of treatment failure in participants with different types of standard valves (early postoperative period: RR 0.41, 95% CI 0.13 to 1.27; at 12 months follow-up: RR 1.17, 95% CI 0.72 to 1.92, very low certainty of the evidence). None of the included studies reported adverse events beyond those included under "treatment failure". We are uncertain about the effects of different types of standard valves on mortality (range 2% to 17%, very low certainty of the evidence). The included studies did not report the effects of these interventions on quality of life, ventricular size reduction or head circumference. 3. Standard valve versus self-adjusting CSF flow-regulating valve One study with 229 randomised participants addressed this comparison. The incidence of treatment failure may be similar in those with standard valves (42.98%) and self-adjusting CSF flow-regulating valves (39.13%) (low certainty of the evidence). The incidence of adverse events may be similar in those with standard valves (range 0 to 1.9%) and those with self-adjusting CSF flow-regulating valves (range 0 to 7.2%) (low certainty of the evidence). The included study reported no deaths in either group in the postoperative period. Beyond the early postoperative period, the authors stated that nine patients died (no disaggregated data by each type of intervention was available, low certainty of the evidence). The included studies did not report the effects of these interventions on quality of life, ventricular size reduction or head circumference. 4. External differential programmable pressure valve versus non-programmable valve One study with 377 randomised participants addressed this comparison. The incidence of treatment failure may be similar in those with programmable valves (52%) and non-programmable valves (52%)  (RR 1.02, 95% CI 0.84 to 1.24, low certainty of the evidence). The incidence of adverse events may be similar in those with programmable valves (6.19%) and non-programmable valves (6.01%) (RR 0.97, 95% CI 0.44 to 2.15, low certainty of the evidence). The included study did not report the effect of these interventions on mortality, quality of life or head circumference. Ventricular size reduction may be similar in those with programmable valves and non-programmable valves (low certainty of the evidence).

AUTHORS' CONCLUSIONS

Standard shunt valves for hydrocephalus compared to anti-syphon or self-adjusting CSF flow-regulating valves may cause little to no difference on the main outcomes of this review, however we are very uncertain due to the low to very low certainty of evidence. Similarly, different types of standard valves and external differential programmable pressure valves versus non-programmable valves may be associated with similar outcomes. Nevertheless, this review did not include valves with the latest technology, for which we need high-quality randomised controlled trials focusing on patient-important outcomes including costs.

Diagnosis of Ventriculoperitoneal Shunt Malfunction: A Practical Algorithm

OBJECTIVE

This study aims to present a practical method to accurately diagnose ventriculoperitoneal shunt (VPS) malfunction and to detect the exact level at which the system has failed to tailor VPS revision at that level only.

METHODS

A tertiary referral single-center algorithm for diagnosis of VPS malfunction is proposed. Based on clinical symptoms and confirmed ventricular dilatation on computed tomography, the VPS reservoir is punctured; if no cerebrospinal fluid is obtained, ventricular catheter replacement is recommended. Conversely, if cerebrospinal fluid is obtained, a sample is sent for cultural examination and the macroscopic integrity of the whole system is checked via plain radiography in the angiographic suite. Then, through the injection of iodate contrast medium into the reservoir and selective exclusion of the proximal and distal catheters, the patency and correct VPS functioning are investigated.

RESULTS

A total of 102 (56 males) patients (mean age, 41.5 years; range, 1-86 years) underwent a VPS function test from 2012 to 2018: 59 cases of VPS malfunction (57.8%) were diagnosed. Ventricular catheter obstruction/damage/displacement occurred in 12/59 patients (20.3%), valve damage in 11/59 patients (18.6%), distal catheter obstruction/damage/displacement in 17/59 patients (28.8%) and 2-level (valve/proximal catheter or valve/distal catheter) obstruction/damage/displacement in 16/59 patients (27.1%). Subclinical infection was diagnosed in 3 patients (5.1%). VPS revision was performed selectively at the level of failure.

CONCLUSIONS

The proposed algorithm is a practical, simple and minimally invasive technique to accurately diagnose VPS malfunction, identifying the exact level of system failure and allowing surgical VPS revision to be tailored, avoiding unnecessary complete system replacement.

Staphylococcus lugdunensis infection of ventriculoperitoneal shunt in adult: Case report and literature review

Ventriculoperitoneal Shunt (VPS) placement is one of the most commonly performed treatment modality in patient with hydrocephalus and infection is usually seen in such patients with shunt complication. Multiple shunt revision and its complications are related to various causes including mainly Coagulase negative Staphylococcus (CONS) infection. VPS obstruction occurring in proximal catheter is he most common cause of VPS malfunction. Here we present a case of Venticuloperitoneal shunt infection caused by CONS in a adult patient.

Occipital Nerve Blocks for Relief of Headaches in Patients With Ventriculoperitoneal Shunts: A Case Series

Pediatric patients with ventriculoperitoneal shunts commonly present with headaches. We report 7 children with ventriculoperitoneal shunts and occipital headaches who received occipital nerve blocks. Eighty-six percent of patients had a history of at least 1 ventriculoperitoneal shunt revision. Headaches improved in every patient after the block. Two patients (29%) were symptom free 11 and 12 months after the block. Four patients (57%) required repeat occipital nerve blocks. Two underwent pulsed radiofrequency ablation. No complications were noted. When patients with ventriculoperitoneal shunts present with headaches, a detailed physical examination is necessary. Persistent occipital headaches with tenderness and radiation in the path of the occipital nerves can be indicative of occipital neuralgia resulting from the shunt having crossed over the path of the greater or lesser occipital nerve. Occipital nerve blocks can help as both diagnostic and therapeutic interventions in these patients.

GAVCA Study: Randomized, Multicenter Trial to Evaluate the Quality of Ventricular Catheter Placement with a Mobile Health Assisted Guidance Technique

BACKGROUND

Freehand ventricular catheter placement may represent limited accuracy for the surgeon's intent to achieve primary optimal catheter position.

OBJECTIVE

To investigate the accuracy of a ventricular catheter guide assisted by a simple mobile health application (mhealth app) in a multicenter, randomized, controlled, simple blinded study (GAVCA study).

METHODS

In total, 139 eligible patients were enrolled in 9 centers. Catheter placement was evaluated by 3 different components: number of ventricular cannulation attempts, a grading scale, and the anatomical position of the catheter tip. The primary endpoint was the rate of primary cannulation of grade I catheter position in the ipsilateral ventricle. The secondary endpoints were rate of intraventricular position of the catheter's perforations, early ventricular catheter failure, and complications.

RESULTS

The primary endpoint was reached in 70% of the guided group vs 56.5% (freehand group; odds ratio 1.79, 95% confidence interval 0.89-3.61). The primary successful puncture rate was 100% vs 91.3% (P = .012). Catheter perforations were located completely inside the ventricle in 81.4% (guided group) and 65.2% (freehand group; odds ratio 2.34, 95% confidence interval 1.07-5.1). No differences occurred in early ventricular catheter failure, complication rate, duration of surgery, or hospital stay.

CONCLUSION

The guided ventricular catheter application proved to be a safe and simple method. The primary endpoint revealed a nonsignificant improvement of optimal catheter placement among the groups. Long-term follow-up is necessary in order to evaluate differences in catheter survival among shunted patients.

CAUSES OF HYDROCEPHALUS AND COMPLICATIONS OF VP SHUNT IN PEDIATRIC POPULATION

ABSTARCT Background: Ventriculoperitoneal (VP) shunt is a common procedure for treatment of hydrocephalus. The objectives of the study were to determine the causes of hydrocephalus and complications of VP shunt in our pediatric population. Materials & Methods: This descriptive, cross-sectional study was conducted in the Department of Neurosurgery, Gomal Medical College, D.I.Khan, Pakistan from January 2018 to January 2019. The sample size was 97 selected through consecutive, non-probability sampling technique using online sample size calculator, the Raosoft. The inclusion criteria were all pediatric patients with hydrocephalus. All those post-operative patient operated for other pathologies of brain and spine without VP shunt were excluded from the study. CT or MRI of brain with and without contrast were done. Post operatively all the patients were followed up till 6 months and any complication which occurred were documented. Demographic variable were sex and age in years. Research variables were causes of hydrocephalus and post-operative complications of VP shunt. All variables except age in years being categorical were analyzed through frequency and percentages. Age was calculated by mean and SD using SPSS version 20. Results: Out of 97 patients, boys were 59(60.82%) and girls were 38(39.17%). The mean age of the sample was 4.5 ±5 ranging from 5 months to 13 years. The most common cause was aqueductal stenosis having 58(59.7 %), myelo-meningocele were 17(17.7%), post meningitis were 12(12.3%) and remaining 10(10.3%) were associated with brain tumors. Out of 21 patients 12(57.2%) developed shunt obstruction, 5(23.8%) shunt infection, 2(9.5%) developed post-operative seizures, 2(9.5%) had exteriorization of lower end of shunt through abdominal incision. Conclusion: The most common cause of hydrocephalus is acqueductal stenosis. The most common complication of VP shunt is shunt obstruction in pediatric population, having pre-school boys as modal group.

Endoscopic third ventriculostomy versus shunt for pediatric hydrocephalus: a systematic literature review and meta-analysis

BACKGROUND

Optimized management of pediatric hydrocephalus remains the subject of debate. Ventriculoperitoneal shunt is largely considered the standard of care. However, the advancements and introduction of new cerebrospinal fluid (CSF) diversion approaches including the use of endoscopic third ventriculostomy (ETV) offer appealing alternatives that have been reported in numerous observational series.

OBJECTIVE

To evaluate the comparative safety and efficacy of shunting and ETV in pediatric hydrocephalus cases.

METHODS

This systematic literature review was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed (Medline) and Cochrane until October 2018. A random effects model meta-analysis was conducted and the I-square was used to assess heterogeneity. The ROBINS-1 tool and Cochrane tool were used to assess risk of bias in the observational and randomized studies, respectively.

RESULTS

Fourteen studies including 8419 patients were identified. Patients in the ETV group had a statistically significant lower risk of infection compared to shunt (OR: 0.19; 95% CI: 0.07-0.53; I²: 0%). All-cause mortality (OR: 0.77; 95% CI: 0.35-1.68; I²: 0%), post-operative CSF leak (OR: 1.53; 95% CI: 0.37-6.31; I²: 0%), and reoperation rates were similar between the two study groups (OR: 0.72; 95% CI: 0.39-1.32; I²: 93.5%). Subgroup analyses for re-operation demonstrated that ETV in Africa (OR: 0.13; 95% CI: 0.03-0.48; I²: 0%) and Europe (OR: 0.39; 95% CI: 0.30-0.52; I²:1.4%) was associated with significantly lower odds of re-operation compared to shunt, but not in USA/Canada (OR: 1.49; 95% CI: 0.85-2.63; I²:86.2%). Meta-regression analyses of age and duration of follow-up did not affect re-operation rates.

CONCLUSIONS

ETV was associated with a statistically significant lower risk of procedure-related infection compared to shunt. All-cause mortality, CSF leak, and re-operation rates were similar between the study groups. Subgroup analysis based on the geographic region showed that ETV is associated with statistically significant lower odds for re-operation in Europe and Africa, but not in USA/Canada. Future RCTs are needed to validate the results of this study and elucidate the cause of this heterogeneity.

Changes of third ventricle diameter (TVD) mirror changes of the entire ventricular system after initial therapy and during follow-up in pediatric hydrocephalus

PURPOSE

Regular measurement of ventricular size is important in children with hydrocephalus. After closure of the fontanelle this is currently addressed by repetitive cranial MRI or CT imaging, coming along with risks of anaesthesia or radiation. As the third ventricle is accessible via the temporal bone window using ultrasound, determination of its diameter might be an easy and radiation-free alternative to assess the ventricular system. An essential precondition is that changes of the third ventricle diameter (TVD) mirror changes of the whole ventricular system. This study compares changes of TVD with changes of ventricular indices before and after initial treatment of hydrocephalus and during the following evolution.

METHODS

MRT/CT images from 117 children with hydrocephalus were evaluated at time of diagnosis, after initial therapy and during follow-up with functional shunts. Measurements included axial TVD and three standard linear measures of the lateral ventricles (Evans Index - EI, fronto-occipital horn ratio - FOHR Index, and Cella Media Index - CMI). Furthermore, a correlation within subjects was calculated in 8 patients over the entire available follow-up.

RESULTS

Relative changes of TVD were significantly correlated to relative changes of all ventricular indices (r = 0.48, r = 0.68 and r = 0.701 for EI, FOHR and CMI, respectively, p < 0.01). The correlation within subjects was outstanding for EI (r = 0.988), FOHR (r = 0.99) and CMI (r = 0.99).

CONCLUSION

TVD showed a significant correlation with all three linear indices at the time of diagnosis and during follow-up changes independently of age, aetiology and ventricular width. TVD and its changes are therefore a reliable surrogate of changes in ventricular size in pediatric hydrocephalus undergoing treatment.