Treatment of cerebrospinal fluid leaks and gram-negative bacillary meningitis with large doses of intrathecal amikacin and systemic antibiotics

Six patients with cerebrospinal fluid (CSF) leaks and gram-negative bacillary meningitis (GNBM) were treated with large doses of intrathecal amikacin (20 to 40 mg daily) and systemic antibiotics. Bactericidal activity was measured in the CSF of each patient, and the dose of intrathecal amikacin was increased if bactericidal activity was absent. Five of six patients had no bactericidal activity with systemic antibiotics alone and/or low dose intrathecal amikacin. All six patients were cured, and three of four patients with vertebral lesions had cessation of CSF leaks within 72 hours of the start of intrathecal amikacin. Intrathecal treatment for 7 to 10 days was adequate for five patients; the CSF of all patients was sterile within 72 hours, and all had a 90% reduction of pleocytosis in the CSF within 96 hours. One patient had radicular back pain after each intrathecal injection, but other side effects were not observed. These findings indicate that CSF leaks associated with GNBM can be effectively treated with large doses of intrathecal amikacin plus systemic antibiotics.     

Multiloculated hydrocephalus related to cerebrospinal fluid shunt infection

Summary This study is an attempt to establish that CSF shunt infection has a role in the aetiology of multiloculated hydrocephalus. The authors carried out a review of 12 cases of multiloculated hydrocephalus who were treated at King Khalid University Hospital between 1988–1994. The multiloculation appears to have developed following the shunt infection in all cases. The hydrocephalus was related to an intraventricular haemorrhage (IVH) in 9 patients and was congenital in 2 patients and post-meningitic in 1 patient. The shunt infection was caused by a gram-negative organism in 8 patients and duration of external ventricular drainage ranged from 9–24 (median 13) days. The diagnosis of multiloculated hydrocephalus was made on average 2 months after the shunt infection. In three patients endoscopic fenestration of intraventricular septations was attempted but was effective in only one case. The other patients were managed by two shunts (9 patients) and three shunts (2 patients). At a mean follow-up of 15 months, the shunt revision rate of the patients was 0.4/year. One patient died of multiple brain abscesses and 6 patients remain severely disabled. The poor outcome may also be related to the original IVH as well as the multiloculated hydrocephalus.The study also shows that patients with post-haemorrhagic hydrocephalus, who develop a shunt infection due to gram-negative organisms and in whom the CSF fails to be cleared of the infection following 12 days of external drainage appear to be at risk of developing multiloculated hydrocephalus.     

Appraisal of cerebrospinal fluid alterations during aortic surgery with intrathecal papaverine administration and cerebrospinal fluid drainage

We have previously described a technique for intrathecal administration of papaverine and cerebrospinal fluid drainage to prevent paraplegia after aortic surgery. Herein we report the cerebrospinal fluid and hemodynamic alterations that occurred in 11 patients who had 30 mg of a specially prepared papaverine hydrochloride 10% dextrose solution injected before aortic cross-clamping and also had cerebrospinal fluid drainage. A mean of 26.6 ml (SD +/- 7.1 ml) was drained before and 34.6 ml (SD +/- 24.1 ml) was drained during aortic cross-clamping. The cerebrospinal fluid pressure increased significantly with anesthetic induction (p less than 0.03), during the period between anesthetic induction and cerebrospinal fluid drainage (p less than 0.005), and with aortic cross-clamping (p less than 0.05). These cerebrospinal fluid pressure alterations were similar to central venous pressure increases with a significant linear correlation between cerebral spinal fluid pressure and central venous pressure before anesthetic induction (r2 = 0.81, p less than 0.005), and both before (r2 = 0.94, p less than 0.005) and after (r2 = 0.74, p less than 0.005) aortic cross-clamping. As expected, cerebrospinal fluid pressure was significantly reduced by cerebrospinal fluid drainage before aortic cross-clamping (p less than 0.001). The administration of intrathecal papaverine had no significant effect on mean arterial pressure, systemic vascular resistance, cerebrospinal fluid pressure, nor the pH of cerebrospinal fluid. Neither were there any complications noted related to the technique. All the patients survived, and no new immediate postoperative paraparesis or paraplegia occurred.(ABSTRACT TRUNCATED AT 250 WORDS)     

Treatment of colloid cysts of the third ventricle by cerebrospinal fluid shunt

The authors report 6 cases of colloid cyst of the third ventricle treated with unilateral ventriculo-atrial shunt and followed up 14 to 3 years. Today the diagnostic of these cysts is safer with C.T.-Scan and M.R.I.; in the 6 cases hydrocephalus was reduced and the volume of the cysts did not increase on C.T.-Scan controls. Nowadays the stereotactic approach seems to be safer than direct surgery but is not always a radical treatment and can be insufficient to treat hydrocephalus. We think that ventricular shunt can be a good alternative as a first and definitive treatment.     

Frequency and causes of shunt revisions in different cerebrospinal fluid shunt types

Summary Shunt complications and revisions are common in hydrocephalic patients treated with a ventriculo-atrial or a ventriculo-peritoneal shunt. The reported revision rate differs very much but the rate of revision is close to 50% in many papers. Data from 884 hydrocephalic patients treated with various shunt types in the period 1958–1989 were recorded retrospectively in order to evaluate the frequency of revision for various shunt types and secondly to analyse the specific reasons for the shunt revisions.The rate of shunt revision was 45%. The Pudenz shunt was revised more often (62%) than the remaining shunt types. The Hakim and the Orbis-Sigma shunts had fewer revisions (35% and 27%, respectively) than the other observed shunt types. A defect of or an obstruction in the ventricular catheters was a frequent cause of revision followed by a defect or an obstruction of the distal catheter, a displacement of the distal catheter and an acute infection. Because of the higher rate of revision for the Pudenz shunt the rate of the above mentioned specific complications is also higher in most of the subgroups for that specific shunt type. Driven by these experiences it is reasonable to seek to develop and introduce new shunt types in an attempt to reduce the complication rate.     

Eosinophilia of the cerebrospinal fluid in a case of shunt infection: case report

A very rare case of eosinophilic granulocytosis of the cerebrospinal fluid (CSF eosinophilia) due to drug allergy caused by the intraventricular administration of gentamicin sulfate is presented with a review of the pertinent literature. An unusual clinical course and clinicoimmunological examination are also described.     

Risk of infection after cerebrospinal fluid shunt: An analysis of 884 first-time shunts

Summary Postoperative infections are major complications of cerebrospinal fluid (CSF) shunting in the treatment of hydrocephalus and other conditions with obstructed CSF circulation. In a retrospective study 884 first-time shunted patients with hydrocephalus operated on in the years 1958–1989 were investigated with special reference to the infection rate and to the influence of the following variables: time period, age of the patient, education of the neurosurgeon, length and time of the operation and the exact placement of the distal drain.The overall infection rate for all implanted CSF shunts was 7.4% (5.7–9.3%) and the acute rate of infection was 6.2% (4.6–7.9%). The rate of infection was virtually constant for all variables with the exception of the education of the neurosurgeon. Neurosurgical trainees particularly had a significantly higher rate of infection.Shunt infection is still a major complication. The infection rate has not declined in recent decades. It is not possible to relate any main cause to the infection rate. The literature recommends removal of the infected shunt combined with antibiotics. The use of prophylactic antibiotics is still controversial. No prospective, double-blind studies, including a sufficiently large number of patients to evaluate this issue, exist today.     

Stretching and breaking characteristics of cerebrospinal fluid shunt tubing

OBJECT: Cerebrospinal fluid (CSF) shunt system malfunction due to silastic tubing fracture necessitates revision surgery in shunt-dependent individuals. The goal of this study was to examine the mechanical stretching and breaking characteristics of new and used CSF shunt tubing catheters to determine if any inherent physical properties predispose the tubing to fracture. METHODS: Fifty-millimeter segments of new and retrieved (used) CSF shunt tubing were stretched to 120 mm in a hydraulic press to determine modulus values (modulus = stress/strain) and to measure permanent tubing deformation imparted by the applied stress and strain. Similar 50-mm tubing segments were also stretched in an electromechanical material testing system until fracture occurred; the force and strain needed to break the tubing was recorded at the time of failure. The results demonstrate that shunt tubing with a greater cross-sectional area requires greater force to fracture, and that catheters become weaker the longer they are implanted. Barium-impregnated shunt tubing, compared with translucent tubing. appears to require less applied stress and strain to break and may fracture more easily in vivo. The variety of modulus values obtained for the new catheters tested indicates that the various companies may be using materials of different quality in tubing manufacture. CONCLUSIONS: A CSF shunt catheter design that incorporates tubing with a greater cross-sectional area may lead to fewer fractures of indwelling catheters and a reduction in shunt revision surgery.     

Determination of cerebrospinal fluid shunt function with water-soluble contrast medium.

Determination of cerebrospinal fluid shunt patency with water-soluble contrast medium is a simple, rapid, reliable, and safe technique. Since September, 1974, the authors performed 113 examinations. With the Spitz-Holter valve, only the atrial catheter can be studied, but, with the Pudenz valve and with the shunting devices that have a double-dome reservoir, both the proximal and the distal catheter can be visualized. Through the ventricular catheter a full ventriculographic study can be made, demonstrating ventricular size, malposition of the catheter, and the lesion that caused the hydrocephalus, or its evolution. The problem of collapsed ventricules, in which clinical and "manual" evaluation of the flushing device can give misleading findings, is emphasized. The injection of the atrial or peritoneal catheter in the pathological cases demonstrated its blockage, level of disconnection, malposition, sleeve, or cyst formation. Computerized tomography has only slightly decreased the number of these studies: when the ventricles are large, the examination with water-soluble contrast medium is still needed to demonstrate the exact level of malfunction. This demonstration has decreased the number of the total revisions complete changes of shunting systems, eliminating some unnecessary changes of normally functioning catheters.     

Determination of cerebrospinal fluid shunt obstruction with magnetic resonance phase imaging

The cerebrospinal fluid (CSF) flow rates in 12 patients with symptoms suggestive of CSF shunt obstruction were measured with magnetic resonance (MR) phase imaging. The shunts were imaged over the skull, just distal to any reservoir, using a curved surface coil. Images perpendicular to the direction of flow were made on a 1.5-tesla clinical unit with a flow-sensitive pulse sequence. The patients' ages ranged from 2 months to 28 years. All patients had ancillary investigations to determine the functional status of the shunt. No flow was detected in seven patients with blocked shunts. Flow rates between 3 and 40 cc/hr were found in three patients with functioning shunts. Two patients, one with a blocked shunt and one with a functioning shunt, could not be imaged due to motion artifact. Magnetic resonance phase imaging is a promising technique in the determination of CSF shunt obstruction.     

Use of telethermography in patients with Holter's cerebrospinal fluid shunt]

The authors describe their experience with thermography in the study of the permeability of Holter's ventriculo-atrial shunt. Thermography has the advantage of permitting immediate visualisation and photographic documentation of the permeability. It appears that the thermographic findings show a good correlation with the functional state of the shunt in 88% of the cases examined. Causes of possible errors are discussed. It is concluded that thermography is a valuable method to assess the patency of Holter's ventriculoatrial shunt.     

Cerebrospinal fluid shunt infection.

There are distinct clinical situations in which the various methods of treatment are generally used: 1. Medical therapy may be used in the circumstance of an infected, but functioning shunt. However, once a shunt is shown to be malfunctioning, it must be treated surgically to correct both the malfunction and the infection. 2. The one combination therapy that continues to treat the hydrocephalus while obeying surgical principles to remove an infected prosthesis is that of immediate shunt replacement. However, this mode of therapy has worked infrequently. 3. The form of combined surgical and medical therapy that allows time to sterilize the CSF in the absence of a foreign body in situ is that of delayed replacement following removal of the infected shunt. However, this method temporarily discontinues the treatment of hydrocephalus. 4. External ventricular drainage removes the foreign body and continues to treat the hydrocephalus; however, this therapy places the patient at increased risk for more virulent infection. With these points in mind, an algorithm for the treatment of shunt infection can be developed as depicted in Figure 8. Using this common sense approach, most circumstances commonly encountered in the practice of pediatric neurosurgery are dealt with, and the best hope of cure is obtained.     

Extremely rare complications in cerebrospinal fluid shunt operations

The cerebrospinal fluid shunt operation, from its first realization in 1908 by Kausch till our days, is still of a significant importance for the long-term treatment of the internal hydrocephalus. Well known are many complications connected with the use of the valve systems (malfunction, infectious, overdrainage, secondary craniosynostosis and etc.). For a period of 17 years (1984-2000) at the Clinic of Pediatric Neurosurgery, Department of Neurosurgery, Sofia Medical University, 414 cerebrospinal fluid shunt operations were performed on children. 216 were drained to the right atrium of the heart, 198 to the peritoneal cavity. They were followed up by catamnesis until the year 2001. The authors describe 2 extremely rare cases with post-shunt complication as a result of a malfunction of the valve system, owing to a migration of the distal catheter: 1) in the anus; 2) in the urethra. In the first case the distal catheter perforated the colon transversum and by the way of the intestines went out through the anus. In the second case the distal catheter protruded out of the body through the bladder and the urethra. Their clinical appearance, the diagnostic examinations and the operative treatment are shown.