Percutaneous fetoscopic spina bifida repair: effect on ambulation and need for postnatal cerebrospinal fluid diversion and bladder catheterization

OBJECTIVE

A trial comparing prenatal with postnatal open spina bifida (OSB) repair established that prenatal surgery was associated with better postnatal outcome. However, in the trial, fetal surgery was carried out through hysterotomy. Minimally invasive approaches are being developed to mitigate the risks of open maternal-fetal surgery. The objective of this study was to investigate the impact of a novel neurosurgical technique for percutaneous fetoscopic repair of fetal OSB, the skin-over-biocellulose for antenatal fetoscopic repair (SAFER) technique, on long-term postnatal outcome.

METHODS

This study examined descriptive data for all patients undergoing fetoscopic OSB repair who had available 12- and 30-month follow-up data for assessment of need for cerebrospinal fluid (CSF) diversion and need for bladder catheterization and ambulation, respectively, from eight centers that perform prenatal OSB repair via percutaneous fetoscopy using a biocellulose patch between the neural placode and skin/myofascial flap, without suture of the dura mater (SAFER technique). Univariate and multivariate logistic regression analyses were used to examine the effect of different factors on need for CSF diversion at 12 months and ambulation and need for bladder catheterization at 30 months. Potential cofactors included gestational age at fetal surgery and delivery, preoperative ultrasound findings of anatomical level of the lesion, cerebral lateral ventricular diameter, lesion type and presence of bilateral talipes, as well as postnatal findings of CSF leakage at birth, motor level, presence of bilateral talipes and reversal of hindbrain herniation.

RESULTS

A total of 170 consecutive patients with fetal OSB were treated prenatally using the SAFER technique. Among these, 103 babies had follow-up at 12 months of age and 59 had follow-up at 30 months of age. At 12 months of age, 53.4% (55/103) of babies did not require ventriculoperitoneal shunt or third ventriculostomy. At 30 months of age, 54.2% (32/59) of children were ambulating independently and 61.0% (36/59) did not require chronic intermittent catheterization of the bladder. Multivariate logistic regression analysis demonstrated that significant prediction of need for CSF diversion was provided by lateral ventricular size and type of lesion (myeloschisis). Significant predictors of ambulatory status were prenatal bilateral talipes and anatomical and functional motor levels of the lesion. There were no significant predictors of need for bladder catheterization.

CONCLUSION

Children who underwent prenatal OSB repair via the percutaneous fetoscopic SAFER technique achieved long-term neurological outcomes similar to those reported in the literature after hysterotomy-assisted OSB repair. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Quantitative Modeling of External Ventricular Drain Output to Predict Shunt Dependency in Aneurysmal Subarachnoid Hemorrhage: Cohort Study

BACKGROUND

Acute hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH); however, attempts to predict shunt-dependent chronic hydrocephalus using clinical parameters have been equivocal.

METHODS

Cohort study of aSAH is treated with external ventricular drainage (EVD) placement at our institution, 2001-2016, via logistic regression. EVD-related parameters included mean/total EVD output (days 0-2), EVD days, EVD days ≤ 5 mmHg, and wean/clamp fails. aSAH outcomes assessed included ventriculoperitoneal shunt (VPS) placement, delayed cerebral ischemia (DCI), radiographic infarction (RI), symptomatic vasospasm (SV), age, and aSAH grades.

RESULTS

Two hundred and ten aSAH patients underwent EVD treatment for a median 12 days (range 1-54); 85 required VPS (40%). On univariate analysis, EVD output, total EVD days, EVD days ≤ 5 mmHg, and wean/clamp trial failures were significantly associated with VPS placement (p < 0.01 for all parameters). No EVD output parameter demonstrated a significant association with DCI, RI, or SV. On multivariate analysis, EVD output was a significant predictor of VPS placement, after adjusting for age and clinical and radiological grades; the optimal threshold for predicting VPS placement was mean daily output > 204 ml on days 0-2 (OR 2.59, 95% CI 1.31-5.07). Multiple wean failures were associated with unfavorable functional outcome, after adjusting for age, grade, and VPS placement (OR 1.65, 95% CI 1.10-2.47). We developed a score incorporating age, grade and EVD parameters (MAGE) for predicting VPS placement after aSAH.

CONCLUSIONS

EVD output parameters and wean/clamp trial failures predicted shunt dependence in an age- and grade-adjusted multivariable model. Early VPS placement may be warranted in patients with MAGE score ≥ 4, particularly following 2 failed wean trials.

Trend in ventricle size during pregnancy and its use for prediction of ventriculoperitoneal shunt in fetal open neural tube defect

OBJECTIVES

Fetal surgery for repair of open neural tube defect (ONTD) typically results in decreased need for a ventriculoperitoneal shunt (VPS). Our objectives were to determine the trend in ventricle size (VS) during pregnancy and whether VS and change in VS, as assessed by ultrasound, were predictive of the need for VPS in pregnancy with ONTD.

METHODS

This was a retrospective analysis of prospectively collected data of consecutive pregnancies with ONTD, evaluated in a single center from January 2012 to May 2018. Two groups were identified: the first consisted of pregnancies that underwent in-utero repair (IUR) and the second those that had postnatal repair (PNR). Penalized B splines were used to determine the trend in VS, across 2-week gestational-age (GA) epochs, between 24 and 36 weeks of gestation. VS at each GA epoch and the change in VS between each GA epoch were compared between the IUR and PNR groups. To determine whether VS at any GA was predictive of VPS, receiver-operating-characteristics (ROC) curves were used and the optimal cut-off at each GA epoch was identified. Univariate analysis and multiple logistic regression were used for further analysis.

RESULTS

ONTD was diagnosed in 110 fetuses, of whom 69 underwent IUR and 41 had PNR. Fetuses in the IUR group were more likely to have Chiari II malformation (100.0% vs 82.9%; P < 0.01), lower GA at delivery (34.9 ± 3.2 vs 37.1 ± 2.1 weeks; P < 0.01) and lower rates of VPS within the first year postpartum (36.2% vs 61.0%; P = 0.02) compared with the PNR group. In both groups, VS increased steadily with GA from the initial evaluation to delivery. In the IUR group, there was a significant change in VS between the 24 + 0 to 25 + 6-week and the 26 + 0 to 27 + 6-week epochs (2.3 (95% CI, 0.4-4.1) mm; P = 0.02). There was a positive trend in the change in VS at later GAs, but this was not significant. Although there was no significant change in VS in the PNR group before 30 weeks, there was a positive trend after that time. On multivariate analysis, each week of advancing GA was associated with a mean increase of 0.74 mm in VS (P < 0.0001) in both groups. VS was not associated with the level or type of lesion, but presence of Chiari II malformation was associated with a mean increase of 5.88 mm (P < 0.0001) in VS in both the IUR and PNR groups. VS was modestly predictive of need for VPS in both groups, with area under ROC curves between 0.68 and 0.76 at the different GA epochs. Change in VS between the first and last measurements was also modestly predictive of the need for VPS, with better performance in the PNR group.

CONCLUSIONS

VS increased with advancing GA in all fetuses with ONTD, although in the IUR group this increase occurred immediately after fetal surgery and in the PNR group it occurred after 30 weeks of gestation. In-utero surgery was associated with a decreased rate of VPS and was more predictive of need for VPS than was VS. Postnatal factors resulting in increased need for VPS in the PNR group need to be assessed further. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Does the skull Hounsfield unit predict shunt dependent hydrocephalus after decompressive craniectomy for traumatic acute subdural hematoma?

Background and purpose

Posttraumatic hydrocephalus affects 11.9%–36% of patients undergoing decompressive craniectomy (DC) after traumatic brain injury and necessitates a ventriculo-peritoneal shunt placement. As bone and arachnoid trabeculae share the same collagen type, we investigated possible connections between the skull Hounsfield unit (HU) values and shunt-dependent hydrocephalus (SDHC) in patients that received cranioplasty after DC for traumatic acute subdural hematoma (SDH).

Methods

We measured HU values in the frontal bone and internal occipital protuberance from admission brain CT. Receiver operating characteristic curve analysis was performed to identify the optimal cut-off skull HU values for predicting SDHC in patients receiving cranioplasty after DC due to traumatic acute SDH. We investigated independent predictive factors for SDHC occurrence using multivariable logistic regression analysis.

Results

A total of 162 patients (>15 years of age) were enrolled in the study over an 11-year period from two university hospitals. Multivariable logistic analysis revealed that the group with simultaneous frontal skull HU ≤797.4 and internal occipital protuberance HU ≤586.5 (odds ratio, 8.57; 95% CI, 3.05 to 24.10; P<0.001) was the only independent predictive factor for SDHC in patients who received cranioplasty after DC for traumatic acute SDH.

Conclusions

Our study reveals a potential relationship between possible low bone mineral density and development of SDHC in traumatic acute SDH patients who had undergone DC. Our findings provide deeper insight into the association between low bone mineral density and hydrocephalus after DC for traumatic acute SDH.

Incidence, diagnostic criteria and outcome following ventriculoperitoneal shunting of idiopathic normal pressure hydrocephalus in a memory clinic population: a prospective observational cross-sectional and cohort study

OBJECTIVE

To evaluate diagnostic criteria for idiopathic normal pressure hydrocephalus (INPH) among patients with memory impairment, and to estimate the incidence of INPH.

DESIGN

Prospective observational cross-section and cohort study of diagnostic accuracy.

SETTING

Memory Disorders Clinic following referral by the medical practitioners.

PARTICIPANTS

408 consecutive patients enrolled 2010-2014.

OUTCOME MEASURES

Reference diagnostic test was the clinical judgement of an experienced specialist based on the presence of cognitive impairment and/or balance and gait disorders in the presence of dilated ventricles. Mini-Mental State Examination (MMSE), Tinetti balance and gait tests were performed before and 12 months after ventriculoperitoneal shunt surgery. The association between reference diagnosis, clinical and brain CT scan measurements was estimated by multivariate Poisson regression. Triage index diagnostic test scores were calculated from the regression coefficients, with diagnostic thresholds selected using receiver operating characteristic analysis.

RESULTS

The presence of balance and/or gait disorders, especially fear of falling, difficulty standing on toes/heals, urinary disturbances, ventriculomegaly with Evans ratio greater than Combined Diagnostic Threshold (0.377-{Maximum width of posterior horns*0.0054}), strongly predict the diagnosis of INPH; while hallucinations and/or delusions and forgetfulness reduce the likelihood of the diagnosis. This triage index test had high sensitivity (95.2%) and specificity (91.7%). 62 of 408 (15%) participants with cognitive impairment had INPH, an incidence of 11.9/100 000/year and 120/100 000/year over 75 years. 96% of participants following shunting, compared with 45% of the non-shunted, improved by over 25% of available measurable improvement in either MMSE or balance/gait scores (51% difference; 95% CI 28% to 74%; p<0.001), and 56% vs 5% improved by over 50% of maximum in both (51% difference; 95% CI 30% to 73%; p<0.001).

CONCLUSION

The triage index test score is a simple tool that may be useful for physicians to identify INPH diagnoses and need for referral for shunt surgery, which may improve cognitive, balance and gait functioning.

Prediction of Shunt Dependency After Intracerebral Hemorrhage and Intraventricular Hemorrhage

BACKGROUND

Spontaneous intracerebral hemorrhage is a disease with high morbidity and mortality. Extension of the hemorrhage into the ventricles is associated with the development of acute hydrocephalus and a poor outcome. Although it can be managed by external ventricular drainage (EVD), a subset of these patients require placement of permanent ventricular shunts. This study aimed to examine the factors on admission that can predict shunt dependency after EVD management.

METHODS

Seventy-two patients who underwent EVD were included in this study. Seventeen of these patients underwent placement of a ventriculoperitoneal shunt. Variables analyzed included age, intraventricular hemorrhage (IVH) score, bicaudate index, acute hydrocephalus, initial Glasgow Coma Scale scores, and blood volume in each ventricle.

RESULTS

In univariate analysis, IVH score (p = 0.020), bicaudate index (p < 0.001), blood volume in lateral ventricles (p = 0.025), blood volume in the fourth ventricle (p = 0.038), and the ratio of blood volume in lateral ventricles to that in third and fourth ventricles (p = 0.003) were significantly associated with persistent hydrocephalus. The best multiple logistic regression model included blood volume parameters and bicaudate index as predictors with the area under a receiver operating characteristic curve of 0.849. The variance inflation factor (VIF) showed that collinearity was not found among predictors. Patients diagnosed with acute hydrocephalus had less blood volume in the lateral ventricles (OR = 0.910) and had more blood volume in the third ventricle (OR = 3.174) and fourth ventricle (OR = 2.126).

CONCLUSIONS

These findings may promote more aggressive monitoring and earlier interventions for persistent hydrocephalus after intraventricular hemorrhage in patients at risk.

Primary External Ventricular Drains in the Management of Open Myelomeningocele Repairs in the Neonatal Setting in Ireland

Aim The aim of this study is to outline the role of primary external ventricular drains (EVD) in the management of open myelomeningoceles in the neonatal setting in Ireland. Methods Retrospective cohort study involving all infants who underwent open myelomeningocele repair in a teritary centre in Ireland between January 2009 and April 2016. Medical charts and laboratory data was reviewed on all infants meeting the inclusion criteria. Results One hundred and forty-three neonates underwent open myelomeningocele repair in the 6.5 year period. EVD were inserted at the time of primary wound closure in 19 cases (13%). EVD were used to aid in wound closure and as a primary method of cerebrospinal fluid (CSF) diversion. They remained in place for a median of 8 days, ranging from 1-22 days. All EVD, apart from one, in our series were replaced by a ventricular-peritoneal (VP) shunt at some stage. Conclusion EVD were used in 13% of cases of open myelomeningocele repairs from Jan 2009-Apr 2016 as a primary measure to aid in management. Compared to the cohort in whom an EVD was not inserted at the time of surgery, there was a decrease in the rate of infections. However, there was an increased rate of wound dehiscence/leak and a later need for VP shunt insertion.

Comparison Of Simultaneous Versus Delayed Ventriculoperitoneal Shunting In Patients Undergoing Meningocoele Repair In Terms Of Infection

BACKGROUND

Myelomeningocele is a congenital anomaly of Central Nervous System (CNS) leading to serious sequels related to various systems and organs of the affected patient. Hydrocephalus is a common condition associated with myelomeningocele. Hydrocephalus is seen in 11.8% of children with Myelomeningocele (MMC). This study was conducted to compare the simultaneous vs delayed ventriculoperitoneal shunting in children undergoing myelomeningocele in terms of infection.

METHODS

This Randomized Control Trial was conducted at department of Neurosurgery, Ayub Medical College, Abbottabad from 7th March to 7th June 2016. In this study a total of 98 patients with MMC and hydrocephalus were randomly divided into two equal groups. In group A simultaneous MMC repair and VP shunting was performed while in group B MMC repair was done in first and VP shunting was done two weeks postoperatively..

RESULTS

In this study mean age in Group A was 1 years with SD±2.77 while mean age in Group B was 1 years with SD±3.12. In Group A (12%) patients had infection and (88%) whereas in Group B (20%) patients had infection and (80%) patients didn't had infection..

CONCLUSIONS

Simultaneous VP shunting was more effective than delayed VP shunting in children undergoing myelomeningocele in terms of infection.

Ventricular Central Neurocytoma: Rate of Shunting and Outcome 2 Years After Total and Subtotal Excision

BACKGROUND

Central neurocytoma is an intraventricular tumor that affects young adults. It has a favorable prognosis after adequate surgical intervention; however, an aggressive course may take place in some cases.

OBJECTIVE

The objective of the study was to evaluate the rate of shunting and the outcome of control measures in patients with central neurocytoma submitted to total and subtotal excision.

METHODS

Twelve patients were included in this study, with a follow-up of 24 months. Data collected included: age, sex, clinical presentation, early morbidity and mortality, radiological findings (tumor location, features, residual, recurrence, and hydrocephalus). All patients underwent surgery for total or subtotal excision through a transcortical approach. External Ventricular Drain (EVD) was inserted then removed or replaced by a shunt. Histopathology and the MIB index were used to confirm diagnosis and guide the follow-up; adjuvant radiotherapy or Gamma Knife radiosurgery were used for residual tumor or recurrence.

RESULTS

The ages of the patients ranged from 14 to 48 years. Two patients died early, after total and subtotal excision, from sepsis and thalamic infarction, respectively. Six patients (60 %) had a total excision; two of them had a high MIB index and showed small recurrence at 12 months and 18 months, respectively, and received Gamma Knife radiosurgery. One of the six patients with total excision needed a shunt, and no shunt was needed in the four otherpatients; a subtotal excision was done for four patients (40 %). An early shunt was inserted for two of these patients, radiosurgery-controlled for one patient, while radiotherapy was used for control in the other three patients; radiotherapy control failed in one patient, who underwent a second surgery at 18 months.

CONCLUSION

Central neurocytoma may have a favorable prognosis, with a lower incidence of shunt insertion throughout its course than that for other intraventricular tumors, if total removal is achieved.

The Rate of Complications after Ventriculoperitoneal Shunt Surgery

BACKGROUND

Although ventriculoperitoneal shunt (VPS) surgery is the most frequent surgical treatment for patients with hydrocephalus, modern rates of complications in adults are uncertain.

METHODS

We performed a retrospective cohort study of adult patients hospitalized at the time of their first recorded procedure code for VPS surgery between 2005 and 2012 at nonfederal acute care hospitals in California, Florida, and New York. We excluded patients who during the index hospitalization for VPS surgery had concomitant codes for VPS revision, central nervous system (CNS) infection, or died during the index hospitalization. Patients were followed for the primary outcome of a VPS complication, defined as the composite of CNS infection or VPS revision. Survival statistics were used to calculate the cumulative rate and incidence rate of VPS complications.

RESULTS

A total of 17,035 patients underwent VPS surgery. During a mean follow-up of 3.9 (± 1.8) years, at least 1 VPS complication occurred in 23.8% (95% confidence interval [CI], 22.9%-24.7%) of patients. The cumulative rate of CNS infection was 6.1% (95% CI, 5.7%-6.5%) and of VPS revision 22.0% (95% CI, 21.1%-22.9%). Most complications occurred within the first year of hospitalization for VPS surgery. Complication rates were 21.3 (95% CI, 20.6-22.1) complications per 100 patients per year in the first year after VPS surgery, 5.7 (95% CI, 5.3-6.1) in the second year after VPS surgery, and 2.5 (95% CI, 2.1-3.0) in the fifth year after VPS surgery.

CONCLUSIONS

Complications are not infrequent after VPS surgery; however, most complications appear to be clustered in the first year after VPS insertion.

Predictors of positive cerebrospinal fluid cultures in infants with bacteremia

BACKGROUND

Meningitis causes substantial morbidity and mortality in hospitalized infants. There is no consensus on the ability of blood cultures to predict results from cerebrospinal fluid (CSF) cultures in hospitalized infants.

METHODS

We used the Pediatrix Medical Group database of infants discharged from 333 neonatal intensive care units between 1997 and 2011. We identified all infants with a positive blood culture and a CSF culture obtained within 3 days. We evaluated the odds of a concordant blood-CSF culture pair, controlling for severity of illness, organism type, gestational age, day of blood culture and blood-CSF culture pairing, exposure to CSF-penetrating antibiotics and the presence of a ventriculo-peritoneal shunt.

RESULTS

We identified 8839 infants with 9408 blood-CSF culture pairs. Serratia marcescens (24/227, 11%) and Streptococcus pneumoniae (7/64, 11%) had the highest proportion of concordant blood-CSF culture pairs. The presence of a ventriculo-peritoneal shunt, as well as timing of the CSF culture on the same day as the blood culture, were associated with increased odds of blood-CSF culture pair concordance-odds ratio = 3.87 (95% confidence interval; 2.59-5.78) and 6.11 (2.81-13.24), respectively.

CONCLUSION

The frequency of blood-CSF culture pair concordance is related to organism type and to the timing of the CSF culture in relation to the blood culture.

Time to First Shunt Failure in Pediatric Patients over 1 Year Old: A 10-Year Retrospective Study

Studies comparing alternatives to ventriculoperitoneal (VP) shunting for treatment of hydrocephalus have often relied upon data from an earlier era that may not be representative of contemporary shunt survival outcomes. We sought to determine the shunt survival rate of our cohort and compare our results to previously published shunt survival and endoscopic third ventriculostomy (ETV) success rates. We identified 95 patients between 1 and 18 years of age, who underwent initial VP shunt placement between January 2001 and December 2010. Our study shows a shunt survival rate of 85% at 6 months and 79% at 2 years, for initial shunts in pediatric patients over 1 year of age in this cohort. The overall infection rate was 3%. This compares favorably with published success rates of ETV at similar time points as well as with the rate of infection. This suggests that ventricular shunting remains a viable alternative to ETV in the older child.

Ventriculoperitoneal shunt surgery and the incidence of shunt revision in adult patients with hemorrhage-related hydrocephalus

OBJECTIVE

Ventriculoperitoneal shunt surgery remains the most widely accepted neurosurgical procedure for the management of hydrocephalus. However, shunt failure and complications are common and may require multiple surgical procedures during a patient's lifetime. The purpose of this study is to evaluate the ventriculoperitoneal shunt surgery and the incidence of shunt revision in adult patients with hemorrhage-related hydrocephalus.

METHODS

Adult patients who underwent ventriculoperitoneal shunt placement for hemorrhage-related hydrocephalus from October 1990 to October 2009 were included in this study. Medical charts, operative reports, imaging studies, and clinical follow-up evaluations were reviewed and analyzed retrospectively.

RESULTS

A total of 133 adult patients with the median age of 54.5 years were included. Among patients, 41% were males, and 62% Caucasians. The overall shunt revision rate was 51.9%. The shunt revision rate within the first 6 months after the initial placement of ventriculoperitoneal shunts was 45.1%. The median time to first shunt revision was 0.50 (95% CI, 0.24-9.2) months. No significant association was observed between perioperative variables (gender, ethnicity, hydrocephalus type, or hemorrhage type) and the shunt revision rate in these patients. Major causes of shunt revision include infection (3.6%), overdrainage (7.6%), obstruction (4.8%), proximal shunt complication (7.6%), distal shunt complication (3.6%), old shunt dysfunction (6.8%), valve malfunction (10.0%), externalization (3.6%), shunt complication (12.0%), shunt adjustment/replacement (24.0%) and other (16.4%).

CONCLUSION

Although ventriculoperitoneal shunting remains to be the treatment of choice for adult patients with post hemorrhage-related hydrocephalus, a thorough understanding of predisposing factors related to the shunt failure is necessary to improve treatment outcomes.

Surgical treatment of myelomeningocele: year 2000 hospitalization, outcome, and cost analysis in the US

OBJECTIVE

To review cases of surgical repair for myelomeningocele (MMC) using a large inpatient database from the year 2000.

MATERIALS AND METHODS

The Nationwide Inpatient Sample (NIS) database with 7.45 million patient admissions for 2000 was retrospectively studied for the first 5 procedure diagnosis of MMC repair (ICD-9 CM procedure code 0352) and ages of less than 1 year. Eighty-eight patient stays were identified. Patient demographic data, length of stay, immediate disposition at the time of discharge, hospital information, and total cost for the hospitalization were determined.

CONCLUSION

Myelomeningocele repair is mostly performed in large teaching institutions in small numbers. The majority gets to go home at discharge. It is surprising to note that only 35% also required VP shunt placement during the same hospitalization.

The changing face of paediatric hydrocephalus: a decade's experience

All 253 children receiving neurosurgical intervention for hydrocephalus (HCP) at a single British Neurosurgical Unit over a decade were investigated by retrospective case note review. Referral rates and mean age at presentation remained stable throughout, as did proportions of children presenting due to myelomeningocoele or meningitis. Comparing the first and second halves of the decade, the predominant aetiologies (intraventricular haemorrhage [IVH] at <1 year and brain tumour at 1-16 years) reduced from comprising half (70/129) of all cases to just over one-third (43/124). Other significant changes included a 45% reduction in neonatal IVH and a 179% increase in rare miscellaneous disorders. Outcome after 4 years of follow-up for all patients showed 44.4% without deficit, 11.9% with non-cognitive neurological deficits only, 11.5% with cognitive impairment only, 13.5% with both cognitive and neurological impairments, and 15.5% mortality.

Influence of shunt surgery on healthcare expenditures of elderly fee-for-service Medicare beneficiaries with hydrocephalus

Object

The goal in this study was to determine the percentage of patients with hydrocephalus who were treated with shunt surgery and to assess Medicare expenditures for those with and without shunt surgery.

Methods

Retrospective cost analyses were performed using the Standard Analytic Files of paid claims for beneficiaries enrolled in both Parts A (Inpatient) and B (Outpatient) of the Medicare program for 1997 through 2001. The main outcome measures were 5-year total payments and 5-year payments for separate types of service; for example, acute hospital (inpatient and outpatient), skilled nursing facility, home health, and physician/supplier services.

Results

Of 1441 patients with hydrocephalus, 25.1% underwent shunt surgery during the study period. The effect of a shunt procedure on 5-year Medicare expenditures is a cost difference of $25,477 (p < 0.0001) less per patient, which is equal to a potential −$184.3 million difference in 5-year Medicare expenditures. The following three factors had a negative association with whether shunt surgery was performed: 1) age 80 to 84 years (odds ratio [OR] 0.619, confidence interval [CI] 0.390–0.984); 2) age 85 years or older (OR 0.201, CI 0.110–0.366); and 3) African-American race (OR 0.506, CI 0.295–0.869). The effect of age on the likelihood of shunt surgery persisted after adjusting for the propensity to die score.

Conclusions

Medicare expenditures for patients with hydrocephalus treated with shunt surgery are significantly lower than expenditures for untreated patients. Research to improve the diagnosis and treatment of hydrocephalus has the potential to improve outcomes and reduce health care expenditures further.

Hospital volumes for common pediatric specialty operations

OBJECTIVES

To describe hospital volumes for common pediatric specialty operations, to evaluate hospital and patient characteristics associated with operations performed at a low-volume hospital, and to evaluate outcomes with hospital volume.

DESIGN

Retrospective cohort using the Kids' Inpatient Database 2003.

SETTING

Discharges from 3438 hospitals in 36 states from 2003.

PARTICIPANTS

Children aged 0 to 18 years undergoing ventriculoseptal defect surgery (n = 2301), tracheotomy (n = 2674), ventriculoperitoneal shunt placement (n = 3378), and posterior spinal fusion (n = 4002).

MAIN EXPOSURE

Hospital volume.

MAIN OUTCOME MEASURES

In-hospital mortality and postoperative complications.

RESULTS

For tracheotomy and posterior spinal fusion, at least one fourth of the hospitals performed only 1 operation for children aged 0 to 18 years in 2003. For these same operations, at least half of hospitals treated 4 or fewer cases per year. For all operations, discharges from low-volume hospitals were less likely to be from children's or teaching hospitals compared with discharges from higher-volume hospitals. For tracheotomy, children were less likely to experience postoperative complications in high-volume hospitals compared with low-volume hospitals (odds ratio, 0.48; 95% confidence interval, 0.21-1.09).

CONCLUSIONS

Many children undergoing common pediatric specialty operations had these procedures performed in low-volume hospitals. Low-volume hospitals were less likely to be children's or teaching hospitals. Children undergoing tracheotomy experienced higher rates of complications in low-volume hospitals. Further research is needed to identify the reasons why so many children have these operations performed in low-volume hospitals.

Analysis of risk factors for infection in coplacement of percutaneous endoscopic gastrostomy and ventriculoperitoneal shunt

Patients with severe neurological impairment requiring tube feeding may have concomitant hydrocephalus. Coplacement of percutaneous endoscopic gastrostomy (PEG) and ventriculoperitoneal (VP) shunting is currently standard in such cases. The present study investigated the risk factors for shunt infection in such patients. The medical records of 23 patients with PEG and VP shunting were retrospectively reviewed. Correlations between shunt system infection and potential risk factors were analyzed including order of PEG and VP shunting, position of abdominal shunt catheter, diabetes mellitus, tracheostomy, and activities of daily living. Twelve patients underwent VP shunting after PEG and 11 underwent PEG after VP shunt placement. Four patients experienced shunt infection, and three required shunt revision. Three of these four patients underwent VP shunting after PEG. The period between PEG and VP shunt placement was 18, 19, and 25 days, shorter than the mean period of 29.3 days. VP shunting can be combined with PEG, but a larger study is required to clearly identify the risk factors. Administration of prophylactic antibiotics and a period of at least 1 month between the procedures are recommended, particularly if the shunt is placed after the PEG tube.

A long-term ventricular drainage for patients with germ cell tumors or medulloblastoma

BACKGROUND

Hydrocephalus associated with intracranial germ cell tumors or disseminated medulloblastoma has been treated with ventriculoperitoneal shunt. However, this procedure has a potential risk of intraperitoneal metastasis of these brain tumors. To prevent this potential risk and to minimize the risk of infection, we developed a percutaneous long-tunneled ventricular drainage (PLTVD). To confirm the effectiveness, we retrospectively analyzed the results of this procedure.

METHODS

From 1979 to 2003, we have treated 96 patients with germ cell tumors and medulloblastoma in our hospital. Of 96 patients, 59 (germ cell tumor, 31; medulloblastoma, 28) had hydrocephalus and 13 needed long-term cerebrospinal fluid drainage to manage the obstructive hydrocephalus due to persistent tumor or communicating hydrocephalus due to dissemination. We performed PLTVD for these cases using a flow-controlled shunt device and percutaneous long-tunneled shunt tube (peritoneal catheter) exiting at the upper abdomen and connecting to a closed drainage system. The occurrence of extraneural metastasis and the incidence of infection were evaluated.

RESULTS

The average duration of drainage was 74 days (range, 34-115 days). All 13 cases received full-dose chemotherapy and radiotherapy without infectious complications or extraneural metastasis.

CONCLUSIONS

Percutaneous long-tunneled ventricular drainage was an effective method to manage long-lasting obstructive or communicating hydrocephalus with germ cell tumors and medulloblastoma.

The predictive value of external continuous lumbar drainage, with cerebrospinal fluid outflow controlled by medium pressure valve, in normal pressure hydrocephalus

BACKGROUND

Although sporadic studies have described temporary external cerebrospinal fluid (CSF) lumbar drainage as a highly accurate test for predicting the outcome after ventricular shunting in normal pressure hydrocephalus (NPH) patients, a more recent study reports that the positive predictive value of external lumbar drainage (ELD) is high but the negative predictive value is deceptively low. Therefore, we conducted a prospective study in order to evaluate the predictive value of a continuous ELD, with CSF outflow controlled by medium pressure valve, in NPH patients.

METHOD

Twenty-seven patients with presumed NPH were admitted to our department and CSF drainage was carried out by a temporary (ELD) with CSF outflow controlled by a medium pressure valve for five days. All patients received a ventriculoperitoneal shunt using a medium pressure valve based upon preoperative clinical and radiographic criteria of NPH, regardless of ELD outcome. Clinical evaluation of gait disturbances, urinary incontinence and mental status, and radiological evaluation with brain CT was performed prior to and after ELD test, as well as three months after shunting.

FINDINGS

Twenty-two patients were finally shunted and included in this study. In a three-month follow-up, using a previously validated score system, overall improvement after permanent shunting correlated well to improvement after ELD test (Spearman's rho = 0.462, p = 0.03). When considering any degree of improvement as a positive response, ELD test yielded high positive predictive values for all individual parameters (gait disturbances 94%, 95% CI 71%-100%, urinary incontinence 100%, 95% CI 66%-100%, and mental status 100%, 95% CI 66%-100%) but negative predictive values were low (< 50%) except for cognitive impairment (85%, 95% CI 55%-98%).

CONCLUSION

This study suggests that a positive ELD-valve system test should be considered a reliable criterion for preoperative selection of shunt-responsive NPH patients. In case of a negative ELD-valve system test, further investigation of the presumed NPH patients with additional tests should be performed.

Central nervous system paracoccidioidomycosis: diagnosis and treatment

BACKGROUND

Paracoccidioidomycosis (PCM) is a systemic mycosis caused by Paracoccidioides brasiliensis. The involvement of the central nervous system (CNS) in paracoccidioidomycosis is higher than previously thought and 2 clinical presentations have been reported, meningitis and pseudotumoral.

METHODS

Twenty medical records of patients with CNS paracoccidioidomycosis treated from 1986 to 2003 were analyzed. The follow-up ranged from 1 to 18 years (mean = 8.9 +/- 4.2).

RESULTS

Besides CNS paracoccidioidomycosis, all patients but one had the chronic systemic form and the pseudotumoral clinical presentation was the most frequent. Based on computed tomography scan findings, 4 image patterns were identified: low-density lesion with ring enhancement, lesion with calcification and ring enhancement, multiloculated low-density lesion with ring enhancement, and diffuse subarachnoid enhancement. The magnetic resonance imaging was performed in 3 patients and showed subarachnoid enhancement in 1 patient and heterogeneous lesion with ring enhancement in 2 patients. Eleven patients were submitted to medical treatment and 9 needed neurosurgical treatment; ventriculoperitoneal shunts in 4 patients, brain lesions resection in 3 patients, and partial resection of spinal cord lesions in 2 patients. Eleven patients had excellent outcome, 4 patients died, 3 are in good clinical condition with residual pulmonary dysfunction, and 1 patient was lost to follow-up.

CONCLUSIONS

The diagnosis of paracoccidioidomycosis with involvement of the CNS is difficult and clinical suspicion is a key point to achieve the correct diagnosis. Patients with early diagnosis have a favorable outcome with clinical or surgical treatment.

Posterior cranial fossa tumours in children at Kenyatta National Hospital, Nairobi

BACKGROUND

The management of children with posterior fossa tumours is a challenge to health care professionals worldwide. Difficulties in diagnosis especially in children less than three years is well documented. Limited diagnostic modalities and lack of awareness of the symptoms and signs as well as societal perception of children's complaints contributes to late presentation. Kenyatta National Hospital Neurosurgical unit is the only specialized unit among the public hospitals in Kenya where such patients are referred.

OBJECTIVE

To review the management of posterior fossa tumours in children at Kenyatta National Hospital.

DESIGN

A retrospective analysis of children treated for posterior fossa tumours at the neurosurgical unit of Kenyatta National Hospital between 1996-2003.

SETTING

Neurosurgery unit, Kenyatta National Teaching and Referral hospital.

RESULTS

Thirty seven children were treated for posterior fossa tumours between 1998 and 2003. Twenty four were females while thirteen were males giving a male: female ratio of 1:1.8. The age varied between 2-16 years with a mean of 6.7 years. Cerebellar symptoms were the most common mode of presentation (30%) followed by headaches and vomiting. Twenty percent of our patients were blind at presentation probably due to chronic effects of raised intracranial pressure. Out of 11 patients with histological diagnosis of meduloblastomas, over 99%, were females and only one was a male. Astrocytomas were evenly distributed at five males and six females. The mean duration of symptoms was 3.7 months while it took eight weeks between time of diagnosis and treatment.

CONCLUSION

Posterior fossa tumours in our set-up are more common in females than in males, M:F ratio of 1:1.8. Over 90% of medulloblastomas are found in female children making it a predominantly female tumour as opposed to available literature. The delay in diagnosis is probably due to lack of information both to the parents and health care providers and expensive diagnostic tools. A high index of suspicion, and a good history and clinical examination is required in the diagnosis of posterior fossa tumours in children especially those below three years.

Intrauterine repair of spina bifida: preoperative predictors of shunt-dependent hydrocephalus

OBJECTIVE

The objective of this study was to determine which factors that are present at the time of intrauterine repair of spina bifida could predict the need for ventriculoperitoneal shunt for hydrocephalus during the first year of life.

STUDY DESIGN

One hundred seventy-eight fetuses have undergone intrauterine repair of spina bifida at Vanderbilt University Medical Center since 1997. Among these, 116 fetuses had a postnatal follow-up period of at least 12 months. The primary outcome of the study was the need for a ventriculoperitoneal shunt for hydrocephalus during the first year of life. The following variables were analyzed: maternal demographics (age, race, gravidity, and parity), gestational age at the time of surgery, ventricular size, degree of hindbrain herniation (determined by magnetic resonance imaging in 33 cases), type of defect (myelomeningocele vs myeloschisis), upper level of the lesion, presence of talipes, and intraoperative use of a lumbar drain. Statistical analysis was performed with logistic regression (to test the association of fetal and maternal factors and the need for ventriculoperitoneal shunting), 2-sample t-tests for comparison of means, and receiver operating curves with the use of the probabilities that were generated by the logistic regression for both continuous and categoric versions of the factors.

RESULTS

Sixty-one of 116 of the fetuses (54%) who underwent operation in utero required the placement of a ventriculoperitoneal shunt before the age of 1 year. The upper level of the lesion was the strongest predictor of shunt requirement (adjusted odds ratio per 1 level increase with the use of continuous variables [S1 through T10], 1.73 [95% CI, 1.22- 2.44]; adjusted odds ratio with the use of upper lesion level >or=L3 vs <L3 as a categorized variable, 5.7 [95% CI, 2.18- 14.7]), followed by gestational age at the time of surgery (adjusted odds ratio per 1 week increase with the use of continuous variables, 1.37 [95% CI, 1.06-1.77]; adjusted odds ratio with the use of gestational age <or=25 weeks vs >25 weeks as a categorized variable, 3.3 [95% CI, 1.28-8.24]), and preoperative ventricular size (adjusted odds ratio per 1 unit increase with the use of continuous variables, 1.17 [95% CI, 1.01-1.36]; adjusted odds ratio with the use of ventricular size >or=14 mm vs <14 mm as a categorized variable, 3.5 [95% CI, 1.08-11.16]). Receiver operating curves with the use of the probabilities that were generated by the logistic regression analyses for both the continuous and categoric versions of the factors were compared. The area under the curve was approximately 0.81 for both methods. Thirty-eight of 48 of the fetuses (79%) with an upper level of the lesion >or=L3 required placement of a ventriculoperitoneal shunt, although 25 of 68 of the fetuses (37%) with lesions <or=L4 did not (P < .0001). Eighty-four percent of the fetuses with a preoperative ventricular size >or=14 mm (27/32 fetuses) needed a shunt compared with 41% of the fetuses (34/81 fetuses) with smaller ventricles (P=.03). Seventy-one percent of the fetuses who underwent operation at >25 weeks of gestation also required shunt placement (37/52 fetuses); 39% of the fetuses (24/61 fetuses) who were treated <or=25 weeks of gestation did not (P=.01). Thirty-five fetuses had a lesion level <or=L4 and a ventricular size <14 mm and underwent operation at <or=25 weeks of gestation. Among these, 8 fetuses (23%) required a ventriculoperitoneal shunt during the first year of life.

CONCLUSION

This study suggests that, among fetuses who underwent operation in utero for spina bifida, fetuses with a ventricular size of <14 mm at the time of surgery, fetuses who had surgery at <or=25 weeks of gestation, and fetuses with defects that were located at <or=L4 were less likely to require ventriculoperitoneal shunting for hydrocephalus during the first year of life.

The influence of surgical operative experience on the duration of first ventriculoperitoneal shunt function and infection

The relationship of surgeon experience, measured by operative volume, to the outcomes of ventricular shunt treatment of hydrocephalus in children is not clear. This paper explores this relationship based on first ventriculoperitoneal shunts (VPS) implanted in English-speaking Canada during the period from April 1989 to March 2001. Three thousand seven hundred and ninety-four first VPS insertions, performed by 254 surgeons, were reviewed. Surgical experience was represented by the number of shunt operations performed during the study period by each surgeon prior to the date of the operation. The 6-month shunt failure risk for less experienced surgeons was 38%, compared to 31% for more experienced surgeons. This difference decreased to 4% at 60 months and 3% at 120 months (p = 0.001). The infection rate for initial shunt insertions was 7% for patients treated by more experienced surgeons and 9.4% for those treated by less experienced surgeons (p = 0.006). A relationship between surgeon experience and shunt outcome that appears to be based on the operative experience that a surgeon brings to a procedure is in keeping with clinical experience. This observation has implications for public policy, service planning and surgical mentorship during the earlier years of a surgeon's career.

Ventriculoperitoneal shunt dysfunction during rehabilitation: prevalence and countermeasures

OBJECTIVE

We examined the prevalence of shunt dysfunction (e.g., overdraining or underdraining malfunctions) in patients with a ventriculoperitoneal shunt and elucidated effective countermeasures of a programmable valve shunt system in treatments for shunt dysfunction during rehabilitation therapy.

SUBJECTS

Among 114 patients with a ventriculoperitoneal shunt for normal pressure hydrocephalus, underdraining appeared in eight patients during hospitalization for rehabilitation therapy, and seven patients experienced overdraining.

RESULTS

We could treat underdraining noninvasively for all six patients with a programmable valve shunt system by decreasing the opening pressure, whereas the other two patients with a fixed valve pressure system required surgical replacement of the valve unit. We could also treat overdraining noninvasively in two cases with programmable valve shunt system by increasing the opening pressure. In two cases with fixed valve pressure system, however, chronic subdural hematomas had to be surgically treated. Either dysfunction interfered with a better functional outcome in rehabilitation therapy. Barthel index after the countermeasures and continuous rehabilitation therapies was significantly larger than the index before the countermeasures in both overdraining and underdraining groups.

CONCLUSIONS

Shunt dysfunction appeared in approximately 13.2% of patients with a ventriculoperitoneal shunt during hospitalization for rehabilitation. The ventriculoperitoneal shunt using programmable valve shunt system was convenient and valuable for treating both overdraining and underdraining malfunctions in the rehabilitation ward.

Clinical outcomes that fetal surgery for myelomeningocele needs to achieve

INTRODUCTION

The development of techniques to close open neural tube malformations prior to birth has generated great interest and hope for fetal interventions and their outcomes. To plan a randomized trial, as is being discussed at three centres in the United States, the determination of what constitutes a clinically significant improvement in outcome is critical. To date, preliminary observations from two centres suggest that improvements may occur, not in spinal cord function as originally postulated, but in the extent of the hindbrain hernia and the frequency that shunting is required to control hydrocephalus.

PURPOSE

The determination of what outcome would constitute an important and clinically significant difference in outcome to be achieved by fetal intervention for myelomeningocele.

METHOD

Parents of patients and patients treated in our myelomeningocele clinic were surveyed using a structured and validated tool. From the perspective of a recommendation to a close friend or family member, the interviewees were asked to quantify on a scale from 0 to 100 the chance of specific outcomes (need for a shunt, need for a wheelchair, change of urinary incontinence) that a fetal operation would need to predictably achieve.

RESULTS

Responses were obtained from 77 patients/families. The fifty percentile response in each study dimension was as follows: the chance of needing a shunt was 12 % (range 0 - 50 %), the chance of needing a wheelchair was 8 % and the chance of being incontinent was 5 % (range 0 - 25 %).

CONCLUSIONS

Fetal interventions will have to achieve significant improvements in the control of hydrocephalus, mobilization and continence over postnatal treatment to be justified.

[Incidence of surgery for hydrocephalus in adults surveyed: same number afflicted by hydrocephalus as by multiple sclerosis]

The incidence of surgical treatment for adult hydrocephalus (older than 18 years) in Sweden from 1996 to 1998 was surveyed. The number of operations was 891 and the average incidence 3.36 operations per 100,000 inhabitants and year, varying regionally from 2.3 to 6.3. The mean age was 60 years (range 18-92), with no sex difference. Normal pressure hydrocephalus (47%) was most common, followed by communicating high pressure hydrocephalus (27%) and aqueductal stenosis (11%). 804 shunt operations (90%) and 67 ventriculostomies (7.5%) were performed, 2% were unclassified.

Ventriculoperitoneal shunt surgery and shunt infections in children with non-tumour hydrocephalus at the Kenyatta National Hospital, Nairobi

OBJECTIVE

To study infections complicating ventriculoperitoneal (VP) shunt surgery in children with non-tumour hydrocephalus at the Kenyatta National Hospital, Nairobi.

DESIGN

A retrospective survey.

SETTING

Kenyatta National Hospital, Nairobi between January 1982 and December 1991.

SUBJECTS

Three hundred and forty five patients who underwent V-P shunt placement for non-tumour hydrocephalus.

RESULTS

Three hundred and forty five patients underwent V-P shunt placement for non-tumour hydrocephalus. There were 107 infection episodes involving 85 patients. The ages of these patients ranged from three months to 12 years. Most of the patients had congenital hydrocephalus. The infection rate was high (24.6%) although comparable to infection rates reported for clean surgery in the hospital. Fever, septic wounds and features of shunt malfunction were the main presenting features. Bacteriological studies confirmed Staphylococcus aureus and coagulase negative staphylococci as the two most commonly isolated micro-organisms.

CONCLUSION

This study emphasises need to reduce infection rate in ventriculoperitoneal shunt surgery at the Kenyatta National Hospital. Definitive surgical treatment for hydrocephalus was in most cases delayed and this problem was also observed during revision of infected shunts. Late presentation was often due to ignorance and the fact that many patients went for traditional forms of treatment first before going to hospital.

Long-term follow-up of shunting therapy

Ventricular CSF shunting surgery has changed the overall outcome figures for hydrocephalic patients over the past three decades. The factors that have improved the outcome are evolution of the shunt systems, improvement of the surgical environment and use of potent antibiotics, technological advances in brain imaging, and refinements in the assessment of cognitive and functional outcomes and of actuarial statistical techniques. But the recent large studies revealed that nearly half of all shunt placements were for revision, and there is a low but real percentage of cases in which death and neurological impairment are related to shunt surgery. The most frequent complication was shunt obstruction, followed by infection, disconnection, hematoma and slit ventricle syndrome. This clearly means that the shunt systems and the techniques in current use involve many problems that have yet to be solved. To solve these problems, new shunt systems should be developed and continuous efforts at reducing shunt infection should be made. The overall complication rate in the authors' series was 31.7%, but we have been able to reduce the complication rate from 37% to 25% by exercising special care focused on the surgical environment and techniques. Careful, long-term follow-up using various parameters and proper statistical analysis is another important factor in improving surgical outcome. Multicenter and international studies will be easier with the development of a network, and it will give us a strong background to treat hydrocephalus.

Predictors of ventriculoperitoneal shunt among babies with intraventricular hemorrhage

We aimed to identify medical care practices that influence the need for ventriculoperitoneal shunt among infants who develop intraventricular hemorrhage. We reviewed the medical records of 82 babies with ultrasonographically documented intraventricular hemorrhage. We compared the 10 babies who required a ventriculoperitoneal shunt to the 72 controls who had intraventricular hemorrhage, but did not require a ventriculoperitoneal shunt or die, prior to discharge. We considered maternal, perinatal, and neonatal risk factors as potential predictive variables. Maternal preeclampsia, prenatal steroids, and cesarean delivery were associated with a reduced risk of shunt. Patients who did require a shunt were more likely than their nonshunted peers to be treated with dopamine, to receive greater volumes of total intravenous fluid, largely as albumin and red blood cells, and to have a higher incidence of acidosis, patent ductus arteriosus and systolic hypertension. Previously identified antecedents and correlates of intraventricular hemorrhage appear also to be the antecedents and correlates of progression to ventriculoperitoneal shunt among infants with intraventricular hemorrhage. These findings are consistent with the possibility that prenatal and postnatal care practices influence the risk for ventriculoperitoneal shunt among babies with intraventricular hemorrhage. This offers the promise that changes in obstetric and neonatal care will reduce the need for ventriculoperitoneal shunt in very low birthweight infants.

Ventriculo peritoneal shunts in children. A ten year experience at the University of Nigeria Teaching Hospital, Enugu-Nigeria

In a ten year period (1977--1986) one hundred and fifty children with hydrocephalus who received ventriculo-peritoneal shunt as their modality of treatment were followed up. Seventy-one per cent of these children were neonates and infants, the majority of them presenting within the first 3 months of onset of symptoms and signs. The major causes of hydrocephalus in these children were congenital malformations, meningitis, tumours and trauma. Pudenz shunt systems were favoured in the 1977--81 period, while 1982--86 period witnessed an upsurge of self devised catheters because of dwindling national economy. The latter were cheaper and more readily available. Apart from blockage of shunts which occurred more in self devised catheters, the performance of these catheters in terms of shunt infections and other complications were same in both self devised and conventional catheters. The main complications encountered were blockage and infection of the shunts, while rare complications included migration and extrusion of shunts to and from the peritoneal cavity, CSF ascites and recurrent abdominal cysts.