What should we do with a discontinued shunt?

Purpose  

The reported rate is up to 10% of shunt disconnection or fracture, either ventriculoperitoneal or subduroperitoneal. However, not all of shunt discontinuity is associated with shunt malfunction. We analyzed the discontinuity of the shunt system and related factors and tried to present a follow-up policy.     

Perforation holes in ventricular catheters—is less more?

Objective  

Obstruction is a common cause of cerebrospinal fluid (CSF) shunt failure. Risk factors for proximal obstructive malfunction are suboptimal ventricular catheter positioning and slit-like ventricles. A new ventricular catheter design to decrease risk of obstruction was evaluated.     

A bizarre reentry phenomenon of distal shunt tip causing shunt malfunction

Introduction

We report a bizarre presentation of a distal shunt malfunction in a 5-year-old child with a ventriculoperitoneal shunt.

Discussion

The plain radiographs done as a workup for possible shunt malfunction demonstrated the distal shunt tip reentering the abdominal wall from inside the peritoneal cavity. We discuss the possible explanation for the phenomenon.

Conclusion

We conclude that the case is just another reminder of the fact that shunt malfunctions can have multiple presentations; hence, a regular follow-up with appropriate imaging and high index of suspicion is mandatory in preventing morbidities.     

Timing of ventriculoperitoneal shunt insertion following spina bifida closure in Kenya

Purpose  

In Western medical centers, emphasis has been placed on simultaneous myelomeningocele closure and ventriculoperitoneal shunting for children with spina bifida (SB) and co-morbid hydrocephalus (HC). This is not practical in developing countries where patients present in a delayed fashion, many with open, dirty myelomeningoceles. The purpose of this study was to evaluate whether timing of shunting in relation to myelomeningocele closure affected shunt-related complications such as SB wound infection, shunt infection, and shunt malfunction.     

Effectiveness and safety of ventriculoperitoneal shunt versus lumboperitoneal shunt for communicating hydrocephalus: A systematic review and meta-analysis with trial sequential analysis

Introduction

The current standard surgical treatment for cerebrospinal fluid diversion is a ventriculoperitoneal shunt (VPS) implantation. Lumboperitoneal shunts (LPS) are an alternative treatment for communicating hydrocephalus. Prior studies comparing these two included a limited number of participants.

Methods

We performed a meta-analysis determined the treatment failure, complications and effectiveness of lumboperitoneal shunt for communicating hydrocephalus. We reviewed studies with clinical and imaging diagnoses of communicating hydrocephalus, all causes and subtypes of communicating hydrocephalus, and studies that analyzed the primary and secondary outcomes listed below. We included randomized controlled trials (RCTs), non-RCTs and retrospective studies. We performed the meta-analysis in R, using a random-effects model and reporting 95% confidence intervals.

Results

Data from 25 studies, including 3654 patients, were analyzed. The total complication rates were 12.98% (188/1448) for lumboperitoneal shunt and 23.80% (398/1672) for ventriculoperitoneal shunt. The odds ratio for lumboperitoneal shunt versus ventriculoperitoneal shunt complication rates was 0.29 (95% CI 0.19 to 0.45, p < 0.0001), and the I² was 72%. The shunt obstruction/malfunction rate was 3.99% (48/1204) for lumboperitoneal shunt and 8.31% (115/1384) for ventriculoperitoneal shunt (Odds ratio 0.54, 95% CI 0.37 to 0.79, p = 0.002, I² = 0%). Based on the Modified Rankin Scale score, there were no differences in effectiveness between lumboperitoneal shunt and ventriculoperitoneal shunt. Nevertheless, lumboperitoneal shunt improved radiological outcomes.

Conclusions

This analysis demonstrated that lumboperitoneal shunt is a safe and equally effective choice for treating communicating hydrocephalus. More studies are needed to confirm the safety of lumboperitoneal shunt.     

Selective use of intra-catheter endoscopic-assisted ventricular catheter placement: indications and outcome

Purpose

In a previous well-controlled study, routine endoscopic-guided placement of ventricular catheters did not seem to decrease the rate of shunt failure or proximal shunt malfunction. Since this study was published, this technique does not seem to gain much acceptance. However, in selected cases, it may assist in accuracy and safety. We therefore have analyzed our experience with selective intra-catheter endoscopic use for ventricular hardware placement.

Methods

We retrospectively collected clinical and radiological data on all children undergoing intra-catheter endoscopic-assisted ventricular catheter placement.

Results

During 25?months, 16 children (ages 3?months–18?years) underwent 18 procedures using the above technique. Indications for surgery were: proximal shunt malfunction with relatively small ventricles (ten children), proximal shunt malfunction with intraventricular membranes (one child), proximal shunt malfunction with distorted ventricles (one child), new shunt with small to medium sized ventricles (two children), or large ventricles and a loculated fourth ventricle secondary to an aqueductal web (two children). Fourteen procedures were technically successful. The catheter was properly located on postoperative imaging in 13 procedures. Frameless navigation was used in three cases.

Conclusions

Selective use of intra-catheter endoscopic-assisted proximal shunt placement is useful and may be indicated in small or distorted ventricles and in cases when fenestration of an intraventricular membrane or aqueductal web is indicated. The main value of such a technique is the ability to accurately place the catheter tip within distorted or small ventricles. Larger series are needed to refine these indications.     

Communicating syringomyelia associated with ventriculoperitoneal shunt malfunction verified with a cerebrospinal fluid dynamic study: case report

History

A 20-year-old male presented with neck pain and motor impairment of the upper extremities because of recurrent syringomyelia caused by ventriculoperitoneal shunt malfunction.

Examination and operation

A computed tomography scan after shuntgraphy demonstrated opacity in the intracranial ventricular system and cervical syrinx with contrast medium, which indicated communication between the fourth ventricle and syrinx. His symptoms resolved immediately after peritoneal catheter replacement, and magnetic resonance images obtained 1 week after surgery showed the complete resolution of hydrocephalus and syringomyelia.

Conclusion

Syringomyelia associated with ventriculoparitoneal shunt malfunction is a well-known complication in myelodysplastic patients; however, this is the first case in which communicating syringomyelia was verified with a cerebrospinal fluid dynamic study. As the present case involved communicating syringomyelia, it could only be resolved by shunt revision surgery.     

Endoscopic third ventriculostomy in previously shunted children: a retrospective study

Purpose

The aim of this study was to assess the mid-term results, success rates, and time-to-failure of secondary endoscopic third ventriculostomy (secondary ETV), as well as the complex management of preoperative and postoperative cares.

Methods

To this purpose, a retrospective analysis of a pediatric population of 22 children who underwent endoscopic third ventriculostomy (ETV) after shunt malfunction (secondary ETV) was performed.

Results

The failure rate, given by the percentage of new shunt replacement in the first 3 months after ETV, was 36%, with a mean time to failure of 14.3 days. All the failures were evident within 1 month after the ETV. Despite the small number of patients in our series, we found no significant correlation between ETV failure and both patient age and hydrocephalus etiology (p?=?0.47 and p?=?0.78, respectively).

Conclusions

In our experience, ETV secondary to shunt malfunction in pediatric patients has a success rate of 64%. As it is a safe and rapid treatment option even in emergency conditions, it is worth performing this procedure in previously shunted children.     

Endoscopic Third Ventriculostomy in Patients with Shunt Malfunction

Objective

This paper presents data from a retrospective study of endoscopic third ventriculostomy (ETV) in patients with shunt malfunction and proposes a simple and reasonable post-operative protocol that can detect ETV failure.

Methods

We enrolled 19 consecutive hydrocephalus patients (11 male and 8 female) who were treated with ETV between April 2001 and July 2010 after failure of previously placed shunts. We evaluated for correlations between the success rate of ETV and the following parameters : age at the time of surgery, etiology of hydrocephalus, number of shunt revisions, interval between the initial diagnosis of hydrocephalus or the last shunt placement and ETV, and the indwelling time of external ventricular drainage.

Results

At the time of ETV after shunt failure, 14 of the 19 patients were in the pediatric age group and 5 were adults, with ages ranging from 14 months to 42 years (median age, 12 years). The patients had initially been diagnosed with hydrocephalus between the ages of 1 month 24 days and 32 years (median age, 6 years 3 months). The etiology of hydrocephalus was neoplasm in 7 patients; infection in 5; malformation, such as aqueductal stenosis or megacisterna magna in 3; trauma in 1; and unknown in 3. The overall success rate during the median follow-up duration of 1.4 years (9 days to 8.7 years) after secondary ETV was 68.4%. None of the possible contributing factors for successful ETV, including age (p=0.97) and the etiology of hydrocephalus (p=0.79), were statistically correlated with outcomes in our series.

Conclusion

The use of ETV in patients with shunt malfunction resulted in shunt independence in 68.4% of cases. Age, etiology of hydrocephalus, and other contributing factors were not statistically correlated with ETV success. External ventricular drainage management during the immediate post-ETV period is a good means of detecting ETV failure.     

Prevalence and characteristics of shunt malfunction without ventricular size change at King Abdulaziz Medical City in Riyadh

Objectives:To determine the prevalence of shunt malfunction without change in ventricle size in imaging modalities, and its clinical presentation.Methods:A cross-sectional study conducted at King Abdulaziz Medical City, Riyadh, from June 2015 to May 2019. Patient’s demographics, clinical presentation and changes in ventricle size were collected. Statistical analysis was done using SPSS version 23.Results:The study included 42 patients who underwent shunt revision. Imaging showed no change in size in 10 (24%) patients, mild enlargement in 8 (19%), and obvious enlargement in 24 (57%). The mean age of diagnosis was 22±16.7. 55% of the patients were males, 45% females. The cause of the malfunction was ventricular catheter occlusion in 14 (34%) patients, 10 (24%) patients had valve-related malfunction, and peritoneal catheter occlusion was present in 6 (14%) patients, and 12 (28%) patients had a combination of the previously mentioned causes. Analysis of the association between ventricular size and headache, vomiting, seizure, confusion, and loss of consciousness in patients with unchanged ventricular size and those with increased ventricular size has shown no statistical significance.Conclusion:Shunt malfunction without ventricular size change was observed in 24% of all shunt malfunction patients. In addition, there was no relationship between ventricular size and patient symptoms.

Hydrocephalus is a serious condition in which cerebrospinal fluid (CSF) accumulates and causes the intracranial pressure to increase. The mean global prevalence of hydrocephalus is 85/100,000.1 The etiology behind hydrocephalus can be divided into 3 causes: an obstruction in the flow of the CSF, a defect in reabsorption of CSF, or overproduction of CSF. Increased intracranial pressure has different presentation based on age group. Neonates, for instance, will have bulging of the fontanelles, which can lead to disproportionate head growth if left untreated. In older children and adults, headache, vomiting and drowsiness are considered the typical symptoms. Obstructive hydrocephalus can be treated by inserting a ventriculoperitoneal shunt. This shunt bypasses the obstruction and drains the CSF into the peritoneum causing intracranial pressure to return to normal. Shunt failure can occur in 11-25% of cases. Failure can be due to obstruction or infection of the shunt. This failure is commonly called a shunt malfunction, and it is generally treated by doing a shunt revision.2,3It is challenging to diagnose a shunt malfunction based on the clinical manifestation alone, which causes more reliance on imaging modalities. These diagnostic imaging modalities include CT scan and MRI. It is possible to confirm shunt failure if the ventricles appear dilated in imaging, a sign upon which physicians sometimes rely. This increased reliance can be disastrous in some cases because the imaging modalities occasionally reveal normal-sized ventricles while the shunt malfunction is present.4 According to a study conducted at Boston Children’s Hospital in 2014 in children who had surgery due to shunt malfunction, CT scan was positive in 65.7% and MRI was positive in 51.4% of patients.5 Another study conducted at Children’s Hospital in Birmingham found that 24% of the imaging results had described the ventricular system as “unchanged”, “stable”, “normal”, “unremarkable”, “small”, “smaller”, “slit”, “negative”, and “no hydrocephalus”.4 There is a lack of researches conducted in Saudi Arabia into imagining reliability in shunt malfunction, which had led to a misleading radiological reports in spite of presence of shunt malfunction. So, this study aimed to determine the prevalence of shunt malfunction without change in ventricle size in imaging. It also defined their characteristics, which included: the part of the shunt that was malfunctioning, and the clinical presentation. The study also investigated previous visits to the hospital with complaints of increased intracranial pressure with negative radiological findings.     

Syringomyelia with quadriparesis in CSF shunt malfunction: a case illustration

Background  

Shunt malfunction typically presents with headaches, vomiting, and impaired consciousness. Paraparesis has been rarely reported as the initial manifestation of valve dysfunction.     

Cerebral vasospasm in shunt infection

Objective  

In bacterial shunt infection, CNS inflammation is a frequently observed complication that may cause vascular complications including vasospasms. Here, we describe the first patient with shunt infection-induced cerebral vasospasms.     

Laparotomy versus Laparoscopic Placement of Distal Catheter in Ventriculoperitoneal Shunt Procedure

Objective

Traditionally, peritoneal catheter is inserted with midline laparotomy incision in ventriculoperitoneal (V-P) shunt procedures. Complications of V-P shunt is not uncommon and have been reported to occur in 5-37% of cases. The aim of this study is to compare the clinical outcomes and the operation time between laparotomy and laparoscopic groups.

Methods

A total of 155 V-P shunt procedures were performed to treat hydrocephalic patients of various origins in our institute between June 2006 to January 2010; 95 of which were laparoscopically guided and 65 were not. We reviewed the operation time, surgery-related complications, and intraoperative and postoperative problems.

Results

In the laparoscopy group, the mean duration of the procedure (52 minutes) was significantly shorter (p < 0.001) than the laparotomy group (109 minutes). There were two cases of malfunctions and one incidence of diaphragm injury in the laparotomy group. In contrast, there were neither malfunction nor any internal organ injuries in the laparoscopy group (p = 0.034). There were total of two cases of infections from both groups (p = 0.7).

Conclusion

Laparoscopically guided insertions of distal shunt catheter is considered a fast and safe method in contrast to the laparotomy technique. This method allows the exact localization of the peritoneal catheter and a confirmation of its patency.     

Quality of life in obstructive hydrocephalus: endoscopic third ventriculostomy compared to cerebrospinal fluid shunt

Purpose  

In the current literature, there are essentially no comparisons of quality of life (QOL) outcome after endoscopic third ventriculostomy (ETV) and shunt in childhood hydrocephalus. Our objective was to compare QOL in children with obstructive hydrocephalus, treated with either ETV or shunt.     

ETV as a last resort

Introduction

The field of neuroendoscopy is rapidly expanding with increasing indications for endoscopic third ventriculostomy (ETV).

Discussion

As a treatment for hydrocephalus, ETV has the advantage of providing a more physiological cerebrospinal fluid diversion without shunt hardware which reduces the risk of recurrent infection and malfunction. The success rate of ETV has been increasing with decreasing morbidity and mortality.

Conclusion

Originally, ETV was indicated for cases of obstructive hydrocephalus, however the indications are expanding. To highlight this, we present a small series of cases were ETV is not traditionally indicated and was a treatment of last choice.     

Torkildsen shunt: re-evaluation of the historical procedure

Objective  

The Torkildsen shunt, which bypasses the cerebrospinal fluid (CSF) flow from the lateral ventricle to the cisterna magna, has been regarded as a historical procedure. We re-evaluated the clinical usefulness of the Torkildsen shunt as a treatment for hydrocephalus in the era of modern neurosurgery.     

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.     

Antibiotic-impregnated ventriculoperitoneal shunts��a multi-centre British paediatric neurosurgery group (BPNG) study using historical controls

Background  

Ventriculoperitoneal shunt infection remains a significant problem. The introduction of antibiotic-impregnated shunt (AIS) systems in the prevention of shunt infection may represent a potential advance; however, there are no randomized controlled trials to establish a robust evidence-based practice. Previously published single-institution cohort studies have provided varying results on the efficacy of AIS systems in the prevention of shunt infection. In this study, we evaluate combined outcomes from three paediatric neurosurgical units in the use of AIS systems for paediatric patients with hydrocephalus.     

A retrospective study of infections after primary VP shunt placement in the newborn with myelomeningocele without prophylactic antibiotics

Purpose  

We aim to correlate the frequency of infections after ventriculoperitoneal (VP) shunt placement in neonates with myelomeningocele (MMC) who did not receive prophylactic antibiotics to the timing of VP shunt placement and the frequency of cerebrospinal fluid (CSF) leakage at the MMC wound.     

Laparoscopic retrieval of disconnected shunt catheters from the peritoneal cavity as a day-case procedure in children—early feasibility report

Purpose  

The aim of this study was to report our experience with laparoscopic retrieval of disconnected shunt catheters in children.