Reconsidering Ventriculoperitoneal Shunt Surgery and Postoperative Shunt Valve Pressure Adjustment: Our Approaches Learned From Past Challenges and Failures

Long-term outcomes of ventriculoperitoneal shunt therapy in idiopathic normal pressure hydrocephalus

BACKGROUND

Limited data are available regarding the long-term functional outcomes and associated factors in patients with idiopathic normal pressure hydrocephalus (iNPH) undergoing ventriculoperitoneal shunt (VPS) placement. This study aimed to retrospectively evaluate the long-term outcomes of iNPH patients treated with VPS.

METHODS

Functional outcomes were assessed preoperatively and at 1-year, 2-year, and 3-year intervals postoperatively using the modified Rankin Scale (mRS), the iNPH grading scale (iNPHGS), and the Mini-Mental State Examination (MMSE).

RESULTS

Significant improvements were observed in mRS and iNPHGS scores at 1, 2, and 3 years post-surgery compared to the baseline level. MMSE scores showed significant improvement at 1-year and 3-year follow-ups. Multivariate regression analysis identified key factors influencing changes in mRS scores: postoperative complications and education level at 1 year, postoperative complications at 2 years, and sex, education level, postoperative complications, and smoking at 3 years. For iNPHGS scores, significant factors included sex, age at surgery, and smoking at 1 and 2 years. Changes in MMSE scores were associated with sex and the duration of preoperative symptoms at 1 year, and postoperative complications, education level, and smoking at 3 years.

CONCLUSION

This study affirmed the efficacy and safety of VPS in managing iNPH. Factors influencing postoperative outcomes predominantly included education level, smoking, duration of preoperative symptoms, and postoperative complications. However, further research is required to validate these findings.

Utilization of a Telemetric Prechamber in the Management of Patients with Normal Pressure Hydrocephalus

BACKGROUND AND OBJECTIVES

Normal pressure hydrocephalus is a preventable and treatable cause of dementia. A telemetric prechamber allows individually tailored ventriculoperitoneal shunt valve adjustments in patients treated with the shunting procedure.

METHODS

In this pilot, prospective randomized trial, 33 adult patients were divided into Group A (with an implanted telemetric prechamber) and Group B (without an implanted telemetric prechamber). The overall condition, Mini-Mental-State-Examination score, and gait test were evaluated 3, 6, 9, and 12 months after surgery. Additionally, the total number of ventriculoperitoneal shunt valve adjustments and their impact on the patient's condition (assessed by the idiopathic normal pressure hydrocephalus scale) were assessed.

RESULTS

There were no differences in the proportion of patients showing improved gait, cognitive functions, or incontinence. Patients with a telemetric prechamber underwent significantly more valve adjustments (1.6 ± 1.1 vs. 0.8 ± 0.6; P = 0.037). Also, a greater difference (reduction) in the shunt initial and final valve setting was observed in the prechamber group (30.71 ± 24.95 vs. 15.26 ± 13.07 mm H2O; P = 0.049).

CONCLUSIONS

A telemetric prechamber allowed more valve adjustments during the follow-up period and a greater difference (reduction) between the initial (perioperative) and final valve pressure settings. However, there was no difference in functional parameters between the groups at any time point of the study.

Efficacy of Ventriculoperitoneal Shunting Using Keen's Point Versus Frazier's Point in Patients With Hydrocephalus: A Non-Randomized Controlled Trial From Pakistan

Background The ventriculoperitoneal (VP) shunt is crucial for draining excess cerebrospinal fluid, preventing complications like elevated intracranial pressure. Common points for the procedure, such as Keen's and Frazier's points, are established, with emerging interest in Choudhary's point. Despite advancements, the challenge remains, as studies reveal cases with incorrectly placed catheter tips, emphasizing the ongoing need for improved ventriculostomy techniques. Objective To assess and compare the efficacy of VP shunting utilizing Keen's point versus Frazier's point in individuals diagnosed with hydrocephalus. Methodology From February to August 2022, this non-randomized controlled trial was conducted at Unit II, Department of Neurosurgery, Lahore General Hospital, Lahore. The study included 438 patients divided into two groups (Group A with Frazier's point and Group B with Keen's point), with 219 patients in each group, allocated based on the attending surgeon's preference. Effectiveness was evaluated post-procedure in the post-surgical ward using CT scans, focusing on factors such as optimal ventricular catheter tip position and minimal brain parenchymal damage. Data analysis utilized IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. Results In the Frazier's point group, the mean age was 18.47±9.21 years, while in the Keen's point group, it was 19.06±10.43 years. The duration of symptoms was 2.59±1.189 months in Frazier's point group and 2.65±1.237 months in Keen's point group. Gender distribution showed 42.5% males and 57.5% females in Frazier's point group and 40.6% males and 59.4% females in Keen's point group. The effectiveness of the VP shunting procedure was observed in 175 (79.9%) cases in Frazier's point group and 133 (60.7%) in Keen's point group (p <0.0001). Conclusion The study concludes that VP shunting at Frazier's point demonstrates superior effectiveness compared to Keen's point, supporting its consideration for hydrocephalus management across pediatric and adult populations.

Nuclear Cerebrospinal Fluid Imaging: Guide to Procedures and Interpretation

Cerebrospinal fluid (CSF) is an essential component of the central nervous system, and disruption of normal CSF flow from the lateral ventricles to the subarachnoid spaces around the brain and spinal canal can have serious consequences. Nuclear imaging may be useful to help diagnose abnormalities in CSF flow; cisternograms can be used to assess for CSF leaks or normal-pressure hydrocephalus, and shuntograms can be used to evaluate for CSF shunt malfunction. The authors review normal and pathologic findings and pitfalls of cisternography and shuntogram examinations. ©RSNA, 2025.

Surgical site infections post-ventriculoperitoneal shunting: A matched healthcare cost and length of stay study: Empirical research quantitative

Aim

To assess the increased hospital length of stay and healthcare costs associated with SSIs among ventriculoperitoneal shunting surgery patients in Jordan.

Design

Retrospective and nested 1:1 pair-matched case-control design.

Methods

A non-probability convenience sample of 48 VP shunt patients was recruited into SSI and non-SSI groups, to standardize the matching variables and exclude their effects as confounders.

Data sources

Patients' electronic medical records from January 2016 to August 2021.

Results

The SSI-group had an extra mean healthcare cost of USD 13,696.53 and a longer hospital length of stay (22.64 mean additional days). Furthermore, Acinetobacter baumanii and Klebsiella pneumonia were identified as being the most predominant causative agents of SSIs.

Conclusion

The results of this study provide baseline data for national and regional benchmarking to evaluate the quality of care provided to likewise patients. Adherence to infection control strategies and protocols considering new surveillance methods of SSIs are encouraged.

Implications for the profession and/or patient care

National benchmarking and remediation are required for post-VP shunting SSIs.

Impact

There are significant associations of SSI post neurosurgery with increased financial burden and wastage of healthcare resources. The findings of this study can be utilized as a standard source for national benchmarking to evaluate the quality of care delivered to likewise patients and promote their infection control measures. Multidrug-resistant bacteria have recently been considered a growing concern for SSIs post-VP shunting. These impacts affect post-VP shunting patients and their healthcare professionals.

Reporting method

EQUATOR's reporting guidelines for Observational studies (STOBE- Strengthening the Reporting of Observational Studies in Epidemiology) have been followed for this research design.

Patient or public contribution

Patients' EMRs were used to source data.

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

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

Implausible, not impossible: delayed supradiaphragmatic thoracic migration of a ventriculoperitoneal shunt in a 17-month-old

BACKGROUND

Intrathoracic migration of a ventriculoperitoneal shunt (VPS) is a phenomenally rare complication, with the supradiaphragmatic intercostal variant even more so. Whereas it can prove debilitating or even fatal via massive hydrothorax, the causative mechanism and proper management of this occurrence are undefined.

CASE PRESENTATION

A 17-month-old girl who had undergone VPS insertion at one month of age was brought to our department for somnolence and dyspnea, which had a sudden onset. Despite a previous thoracostomy provided temporary symptom relief, she had relapsed. Computed tomography (CT) of the chest showed a large loop of the right-sided VPS penetrating into the thorax through the anterior wall, as well as marked right hydrothorax. She was subjected to VPS revision and thoracostomy, with the swift, complete, and lasting remission of her complaints.

CONCLUSION

It is possible that local reaction coupled with negative inspiratory pressure caused the catheter loop to break into the pleural cavity. Our case demonstrates an exceedingly rare event that has a favorable prognosis if diagnosed and treated quickly and appropriately.

Dynamic plain abdominal film provides simple and effective diagnosis of delayed shunt insufficiency caused by abdominal adhesions after VP shunt

BACKGROUND

Many complications may occur after placement of the ventriculoperitoneal shunt (VP shunt) for hydrocephalus, and delayed shunt insufficiency (DSI) is among the most common. It is often caused by abdominal adhesions, which increases the difficulty of diagnosis. This study aimed to explore the clinical value of dynamic plain abdominal radiography (DPAR) as a simple diagnostic method for patients with DSI due to terminal adhesion of the peritoneal shunt after VP surgery.

METHODS

A total of 30 patients with high suspicion of DSI due to abdominal adhesions after VP surgery were included. DPAR was used for prospective assessment. The interval between the first and second PAR was 4-6 h before surgery. If two plain abdominal radiography at different times indicated that the end of the shunt tube in the abdominal segment was fixed, it was diagnosed as DSI due to adhesion of the shunt tube at the abdominal end. The peritoneal end of the shunt tube was surgically repositioned. Postoperative DPAR was repeated to evaluate the distance of the shunt outlet within the abdominal segment.

RESULTS

All cases showed clinical symptoms or imaging findings of shunt insufficiency. The diagnostic accuracy of DPAR was 96.67% (29/30). The end of the shunt tube in the abdominal segment of the preoperative group was fixed with abdominal plain film twice with a mean difference of 1.74 ± 1.18 cm. The mean postoperative change in the position of the end of the shunt tube in the abdominal section was 9.36 ± 2.64 cm, showing a significant difference compared with the preoperative group (P < 0.001). The mean postoperative EVANs index (0.37 ± 0.08) was significantly lower than the preoperative (0.42 ± 0.08) (P = 0.007), Glasgow coma scale score (12.8 ± 2.69) was higher than the mean preoperative score (11.36 ± 2.43) (P = 0.013).

CONCLUSION

DPAR is a simple and effective method for the diagnosis of shunt insufficiency caused by delayed abdominal end adhesion after VP shunt.

Reducing radiation exposure and costs: CT body scout views with an enhanced protocol versus conventional radiography after shunt surgery

OBJECTIVE

Ventriculoperitoneal shunt implantation has become standard treatment for cerebrospinal fluid diversion, besides endoscopic third ventriculostomy for certain indications. Postoperative X-ray radiography series of skull, chest and abdomen combined with cranial CT are obtained routinely in many institutions to document the shunt position and valve settings in adult patients. Measures to reduce postoperative radiation exposure are needed, however, there is only limited experience with such efforts. Here, we aim to compare routine postoperative cranial CT plus conventional radiography series (retrospective arm) with cranial CT and body scout views only (prospective arm) concerning both diagnostic quality and radiation exposure.

PATIENTS AND METHODS

After introduction of an enhanced CT imaging protocol, routine skull and abdomen radiography was no longer obtained after VP shunt surgery. The image studies of 25 patients with routine postoperative cranial CT and conventional radiography (retrospective arm of study) were then compared to 25 patients with postoperative cranial CT and CT body scout views (prospective arm of study). Patient demographics such as age, sex and primary diagnosis were collected. The image quality of conventional radiographic images and computed tomography scout views images were independently analyzed by one neurosurgeon and one neuroradiologist.

RESULTS

There were no differences in quality assessments according to three different factors determined by two independent investigators for both groups. There was a statistically significant difference, however, between the conventional radiography series group and the CT body scout view imaging group with regard to radiation exposure. The effective dose estimation calculation yielded a difference of 0.05 mSv (two-tailed t-test, p = 0.044) in favor of CT body scout view imaging. Furthermore, the new enhanced protocol resulted in a reduction of cost and the use of human resources.

CONCLUSION

CT body scout view imaging provides sufficient imaging quality to determine shunt positioning and valve settings. With regard to radiation exposure and costs, we suggest that conventional postoperative shunt series may be abandoned.

Optimization of number and range of shunt valve performance levels in infant hydrocephalus: a machine learning analysis

Shunt surgery is the main treatment modality for hydrocephalus, the leading cause of brain surgery in children. The efficacy of shunt surgery, particularly in infant hydrocephalus, continues to present serious challenges in achieving improved outcomes. The crucial role of correct adjustments of valve performance levels in shunt outcomes has been underscored. However, there are discrepancies in the performance levels of valves from different companies. This study aims to address this concern by optimizing both the number and range of valve performance levels for infant hydrocephalus, aiming for improved shunt surgery outcomes. We conducted a single-center cohort study encompassing infant hydrocephalus cases that underwent initial shunt surgery without subsequent failure or unimproved outcomes. An unsupervised hierarchical machine learning method was utilized for clustering and reporting the valve drainage pressure values for all patients within each identified cluster. The optimal number of clusters corresponds to the number of valve performance levels, with the valve drainage pressure ranges within each cluster indicating the pressure range for each performance level. Comparisons based on the Silhouette coefficient between 3-7 clusters revealed that this coefficient for the 4-cluster (4-performance level) was at least 28.3% higher than that of other cluster formations in terms of intra-cluster similarity. The Davies-Bouldin index for the 4-performance level was at least 37.2% lower than that of other configurations in terms of inter-cluster dissimilarity. Cluster stability, indicated by a Jaccard index of 71% for the 4-performance level valve, validated the robustness, reliability, and repeatability of our findings. Our suggested optimized drainage pressure ranges for each performance level (1.5-5.0, 5.0-9.0, 9.0-15.0, and 15.0-18.0 cm H2O) may potentially assist neurosurgeons in improving clinical outcomes for patients with shunted infantile hydrocephalus.

Automatic assessment of disproportionately enlarged subarachnoid-space hydrocephalus from 3D MRI using two deep learning models

Background

Disproportionately enlarged subarachnoid-space hydrocephalus (DESH) is a key feature for Hakim disease (idiopathic normal pressure hydrocephalus: iNPH), but subjectively evaluated. To develop automatic quantitative assessment of DESH with automatic segmentation using combined deep learning models.

Methods

This study included 180 participants (42 Hakim patients, 138 healthy volunteers; 78 males, 102 females). Overall, 159 three-dimensional (3D) T1-weighted and 180 T2-weighted MRIs were included. As a semantic segmentation, 3D MRIs were automatically segmented in the total ventricles, total subarachnoid space (SAS), high-convexity SAS, and Sylvian fissure and basal cistern on the 3D U-Net model. As an image classification, DESH, ventricular dilatation (VD), tightened sulci in the high convexities (THC), and Sylvian fissure dilatation (SFD) were automatically assessed on the multimodal convolutional neural network (CNN) model. For both deep learning models, 110 T1- and 130 T2-weighted MRIs were used for training, 30 T1- and 30 T2-weighted MRIs for internal validation, and the remaining 19 T1- and 20 T2-weighted MRIs for external validation. Dice score was calculated as (overlapping area) × 2/total area.

Results

Automatic region extraction from 3D T1- and T2-weighted MRI was accurate for the total ventricles (mean Dice scores: 0.85 and 0.83), Sylvian fissure and basal cistern (0.70 and 0.69), and high-convexity SAS (0.68 and 0.60), respectively. Automatic determination of DESH, VD, THC, and SFD from the segmented regions on the multimodal CNN model was sufficiently reliable; all of the mean softmax probability scores were exceeded by 0.95. All of the areas under the receiver-operating characteristic curves of the DESH, Venthi, and Sylhi indexes calculated by the segmented regions for detecting DESH were exceeded by 0.97.

Conclusion

Using 3D U-Net and a multimodal CNN, DESH was automatically detected with automatically segmented regions from 3D MRIs. Our developed diagnostic support tool can improve the precision of Hakim disease (iNPH) diagnosis.

The incidence of VP shunt infection in a middle-income nation: a retrospective analysis of a pediatric population

OBJECTIVE

To investigate the incidence of infection after ventriculoperitoneal shunt (VPS) insertion at the Bustamante Hospital for Children (BHC), Jamaica, West Indies.

METHOD

Of the 178 patients managed by the Neurosurgery team at BHC, who underwent surgery between 2010 and 2016, 122 patients were subjected to the cerebrospinal fluid (CSF) diversion procedure through a VPS placement. The patients excluded from this study included those with a VPS placed at another institution or one placed prior to the study period. There is a notable transition that saw a switch from the use of the Codman uni-port to Medtronic shunts in 2014-2015, which initiated the process of reuse of shunt passers. Clinical data were retrospectively collected from operating theater logs and available manual health records.

RESULTS

Over the 7-year study period of the 122 first-time shunt placements done, 17 patients (13.9%) had positive CSF cultures, with an additional six (4%) having CSF pleocytosis with negative cultures. The most common isolate was the Staphylococcus species, occurring in 60% of VPS infections. The median time to shunt infection was 2 months. Of the 72 Codman shunts placed, six became infected, and 21.7% (10 of 46) of the Medtronic shunts became infected.

CONCLUSION

The rate of incidence of VPS infection was 13.9% for the period between 2010 and 2016, with most infections occurring after 2014. The major causative agent was Staphylococcus species at 60% within a median 2 months of surgery. Overall, this compares well with data reported in the literature.

Right Transcephalic Ventriculo-Subclavian Shunt in the Surgical Treatment of Hydrocephalus-An Original Procedure for Drainage of Cerebrospinal Fluid into the Venous System

The objectives of this article are to present an original surgical procedure for the temporary or definitive resolution of hydrocephalus, in the case of repeated failure of standard treatment techniques, and to present a case that was resolved using this surgical technique.

MATERIALS AND METHODS

We present the case of a 20-year-old male patient with congenital hydrocephalus who underwent a number of 39 shunt revisions, given the repetitive dysfunctions of various techniques (ventriculo-peritoneal shunt, ventriculo-cardiac shunt). The patient was evaluated with the ventricular catheter externalized at the distal end and it was necessary to find an emergency surgical solution, considering the imminent risk of meningitis. The patient was also associated with the diagnosis of acute lithiasic cholecystitis.

RESULTS AND DISCUSSIONS

The final chosen solution, right ventriculo-venous drainage using the cephalic vein, was a temporary surgical solution, but there are signs that this procedure can provide long-term ventricular drainage.

CONCLUSIONS

Transcephalic ventriculo-subclavian drainage represents an alternative technical option, which can be used when established options become ineffective.

Case report: Ventriculoperitoneal shunt disconnection resulting in migration of the distal catheter entirely into the abdominal cavity due to seizure

Ventriculoperitoneal (VP) shunt disconnection, a VP shunt complication, can be caused by several factors. We report the case of a young man who suffered VP shunt disconnection, and whose entire distal catheter migrated into the abdominal cavity due to a seizure. To our knowledge, risk factors for seizures related to shunt disconnection have not been previously evaluated. We report this rare case to highlight the fact that seizures are not negligible in increasing the probability of disconnection and migration of the entire distal catheter into the abdominal cavity, and the standardized treatment of traumatic seizures is extremely important.