Ventriculitis and hydrocephalus caused by Candida albicans successfully treated by antimycotic therapy and cerebrospinal fluid shunting.

A unique case of Candida albicans ventriculitis and hydrocephalus in the absence of any evidence of systemic candidiasis or immunosuppression is reported. Initial treatment with CSF shunting and intravenous antimycotic therapy appeared to have eradicated the infection. Recurrence occurred 5 months after discharge and this was treated by intravenous and intrathecal antimycotic therapy in addition to removal of the shunt system, external ventricular drainage and then replacement of the shunt. A concomitant pyogenic brain abscess responded to burrhole aspiration and antibiotics. The role of mannan antigen monitoring is discussed.     

Persistent CSF leucocytosis associated with intrathecal gentamycin

A case where the administration of intrathecal gentamycin, used to treat a ventriculitis consequent upon a ventriculoperitoneal shunt infection, with a persistent elevation of the CSF leucocyte count is described. In a situation where the number of white cells in the CSF is taken to indicate resolution of infection, it is important to recognise that apparent failure of resolution of infection may be due to the gentamycin itself and not persistent infection.     

Intrathecal colistin for treatment of highly resistant Pseudomonas ventriculitis. Case report and review of the literature

Nosocomial infections with organisms resistant to multiple antibiotic agents represent an evolving challenge in the intensive care setting, particularly in patients requiring surgical diversion of cerebrospinal fluid. The authors present the case of a 51-year-old woman who endured protracted hospitalization and required multiple surgeries including placement of a ventriculoperitoneal shunt. The shunt subsequently became colonized with Pseudomonas aeruginosa, which demonstrated intermediate sensitivity to amikacin and full resistance to all other antibiotics tested 'After failing to respond to intravenous imipenem as well as intravenous and intrathecal amikacin, the patient was successfully treated with intravenous and intrathecal colistin. Colistin is a polymyxin-type antibiotic, rarely used outside of topical application because of reported nephrotoxicity associated with parenteral administration. With activity limited to Gram-negative organisms, colistin is bactericidal by directly disrupting the structure of cell membranes. Authors of a few case reports in the literature have described successful treatment of various ventriculitis with the intrathecal administration of colistin. With bacterial resistances outpacing the pharmaceutical industry's ability to develop novel antibiotics, colistin represents an important alternative in situations involving multidrug-resistant organisms.     

Treatment of cerebrospinal fluid and syringosubarachnoid shunt infection with systemic and intrathecal antibiotics

We present a case of a patient with two preexisting Silastic syringosubarachnoid shunt catheters who developed Enterobacter meningitis. The infection was treated successfully with systemic and intrathecal antibiotics without removal of the catheters. With careful sequential clinical and laboratory monitoring, even this type of cerebrospinal fluid shunt infection can be eradicated without catheter removal and replacement.     

Nontuberculous mycobacterial exit-site infection and abscess in a peritoneal dialysis patient

Nontuberculous mycobacterial infections of peritoneal dialysis catheter exit sites have rarely been reported in patients on peritoneal dialysis. We report here a case of Mycobacterium abscessus exit site infection with abdominal wall abscess formation in an adolescent on peritoneal dialysis, which required long-term antibiotic therapy, peritoneal dialysis catheter removal, and surgical debridement of the abscess. Nontuberculous mycobacteria should be considered as a possible causative organism for an exit site infection that fails to respond to usual antibiotic therapy. Nontuberculous mycobacterial exit site infections may require peritoneal dialysis catheter removal and surgical debridement.     

Intrinsic spinal cord catheter placement: implications of new intractable pain in a patient with a spinal cord injury

We present a case of new intractable flank pain after intrathecal infusion system placement in a 45-yr-old man with a history of a T12 spinal cord injury with dysesthetic leg pain. Pain after intrathecal infusion system placement was evaluated by magnetic resonance imaging and the catheter was found to be intraparenchymal. The patient was treated by cessation of infusion and surgical removal of the system. Before surgical removal, the pump was turned off and the patient's flank pain resolved. Increased vigilance is warranted when caring for paraplegic patients. When new pain persists, intrathecal medication tapering should be considered.     

Fenestration of intraventricular cysts using a flexible, steerable endoscope and the argon laser

Two infants with hydrocephalus and compartmentalization of the lateral ventricles due to cerebrospinal fluid infection were treated by fenestration of the ventricular cysts using the argon laser through a steerable flexible endoscope. Both children had undergone failed multiple shunting procedures that attempted to drain the lateral ventricular cysts. One child had chronic granulomatous disease and persistent Candida ventriculitis and meningitis. His infection resolved after removal of multiple shunt systems was made possible by endoscopic laser fenestration to convert a multilocular to a unilocular hydrocephalus. Postoperative computed tomographic scans and head circumference measurements showed arrested hydrocephalus in both cases, and both children remain symptom-free 6 months after operation. The argon laser was used to coagulate and incise the ventricular septae in both cases. The steerable flexible endoscope enabled excellent visualization of the ventricular system without manipulation of the endoscope at the corticotomy site. Necessary improvements in the design of the flexible endoscope and the delivery system for the argon laser are discussed.     

Stereotactic removal of a migrating ventricular catheter

Retained ventricular catheters are usually well tolerated but, when infection is present, their removal becomes imperative because such catheters serve as a nidus for persistent infection. Minimally invasive methods for the removal of retained catheters are desirable. The removal of an infected, retained, subcortical ventricular catheter using stereotactic techniques is described. The authors think that this method is a safe and effective first step in dealing with this difficult problem.     

Continuous intrathecal infusion of baclofen in patients with spasticity caused by spinal cord injuries

The aim of this study was to determine the efficacy and safety of intrathecal baclofen therapy delivered by a programmable pump for the chronic treatment of spinal spasticity. Twelve patients with intractable spasticity caused by spinal cord injuries underwent implantation of a programmable continuous infusion pump after significant reduction in spasticity following an intrathecal test bolus of baclofen. No deaths or new permanent neurological deficits occurred following surgery or chronic intrathecal baclofen therapy. The follow-up (12 months) shows a reduction in rigidity in the lower limb of 2.0 points on the Ashworth scale and in the upper limb of 1.2 points. Muscle spasms were reduced from a mean preoperative score of 2.8 to a mean postoperative score of 1.0. In two cases, we observed postoperative catheter dislocation, a complication which could be corrected surgically. This study demonstrates that chronic intrathecal baclofen infusion is a safe and effective form of treatment of intractable spasticity in patients with spinal cord injury. There is considerable reduction in the risk of infection in view of the fact that interrogation and programming of the implanted programmed pumps is noninvasive. Electronic Publication     

Ventriculoatrial shunt infection due to Cryptococcus neoformans: an ultrastructural and quantitative microbiological study

A 28-year-old man presented with hydrocephalus due to an infection by Cryptococcus neoformans involving his ventriculoatrial shunt. Ultrastructural studies of the ventriculoatrial shunt demonstrated yeastlike organisms consistent with C. neoformans within a biofilm on the appliance. Quantitative microbiological studies of segments of the shunt demonstrated C. neoformans in a concentration gradient from 9 X 10(6) colony-forming units (CFU)/0.5-cm section involving the ventricular portion of the catheter to 1 X 10(2) CFU/0.5-cm section at the vascular tip. The clinical, microbiological, and ultrastructural data suggest that this cryptococcal infection started as a ventriculitis or encephalitis with extension to the meningeal surface. Future application of these methods may further elucidate the pathogenesis of ventriculoatrial shunt infections.     

Shunt malfunction in relation to shunt infection

Summary Ventriculo-peritoneal shunt malfunction may be caused by shunt infection which may not be clinically apparent as the cause of the malfunction by standard diagnostic criteria. This suggests that the real incidence of infected shunts might be higher than previously suspected. In order to study the relationship between infection and shunt malfunction, we followed a protocol over five years (54 V-P shunts) consisting of (1) removal of the malfunctioning shunt and replacement in the same surgical procedure with a new one or institution of an external ventricular drainage for 8 days (if there were clear signs of infection), (2) culturing of CSF and every part of the removed shunt, and (3) intravenous antibiotic treatment (Vancomycin 1g./12h + Ceftriaxone 1g./12h) for five days after the new V-P shunt had been inserted. In those cases in which an external ventricular drainage had been placed, its tip and a portion of the new V-P shunt were also cultured. The results showed that although CSF cultures were negative in 49/54 cases (90.7%), cultures of the removed shunts were positive in 32/54 (59.2%), most of them (21/32, 65.6%) for Staphylococcus coagulase negative organisms.The CSF samples obtained by puncturing the reservoir on admission to Hospital were positive only in 5 out of 54 cases (9.2%), only in those showing clinical features of infection. In the remaining cases, 27 out of 54 (50%) the CSF cultures were negative but the shunt cultures proved positive and required further treatment.For the newly inserted shunts (173) CSF was collected through the shunt during the surgical procedure, and a small piece of the extra-tube from the ventricular and from the peritoneal catheter were obtained and cultured. All the six shunts (6/173, 3.4%) that showed positive cultures after insertion had to be replaced within a period of three to four weeks due to malfunction (range 26±7 days), indicating that the systematic culture of CSF and tubing helps to predict which shunts will soon need to be replaced due to infection.We conclude that CSF culture alone does not rule out infection in cases of shunt malfunction. The percutaneous CSF obtained from the shunt reservoir on admission is particularly prone to show negative cultures even when the shunt is colonized by bacteria.     

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.     

Management of posthemorrhagic hydrocephalus in the preterm infant

We studied the use of a subcutaneous ventricular catheter reservoir in 19 preterm infants with birth posthemorrhagic hydrocephalus. These infants were a poor risk for insertion of ventriculoperitoneal shunt due to their small size and hemorrhagic ventricular fluid at the time of diagnosis. The age at reservoir insertion was 29 +/- 9 days and the weight was 1,217 +/- 414 g. The reservoir was kept in place for 51 +/- 29 days with the removal of 527 +/- 421 mL of fluid by 57 +/- 42 taps. All infants tolerated the procedure well. Only two infants developed infection despite multiple reservoir taps. One infant expired due to unrelated causes. Three infants did not require a permanent shunt, while 15 infants had a ventriculoperitoneal shunt inserted prior to discharge at 3 to 4 months of age. We conclude that ventricular catheter reservoir is a safe and effective palliative procedure in the management of post hemorrhagic hydrocephalus in small preterm infants.     

A flexible metal ventricular catheter for treatment of complicated and protracted infections of the cerebrospinal fluid spaces: Preliminary experiences

Summary In the management of shunt infection, the use of ventricular catheters made of silicone rubber for the temporary external drainage of cerebrospinal fluid (CSF) is general practice. However, the eradication of the primary source of infection may be hindered by the affinity of bacteria to silicone-based material. Compared to silicone catheters, a metal drainage device for temporary ventriculostomy appears to offer more favourable conditions for successful eradication of the infection. Since metal needles cannot be implanted permanently and since their screw-type fixation precludes attachment to the skulls of infants or small children, we developed a flexible metal catheter. This catheter was used exclusively for the treatment of particularly serious or chronic infections of the CSF spaces. The catheter is made of implantation steel and consists of a corrugated tube that renders it flexible. Cerebrospinal fluid drains into a receptable bulb at the tip of the tube. Tubing of other materials may be connected to the end of the metal catheter for either external or internal drainage. It was implanted as a temporary and later permanent CSF drainage in 7 male patients aged from 4 to 60 years, who suffered from chronic, recurrent ventriculitis (n = 5) with an average of 7 previous surgical revisions, as well as from complex infections (n = 2; basal tuberculous meningitis, brain abscess). The infections were successfully eliminated in 6 patients. In the remaining patient, the metal catheter for external ventriculostomy had to be removed after 4 days due a leakage of CSF; it was replaced by a silicone catheter and later on by a needle drainage. Other complications, such as secondary infection or intracerebral haemorrhage, did not occur. The average duration of external CSF drainage via the flexible metal catheter was 27 days (range 4–50 days). In 4 patients, the CSF drainage was converted to a permanent ventriculoperitoneal shunt using a new flexible metal catheter. At the time of post-operative follow-up examination (average = 34 weeks), all shunts were functioning and there was no evidence of infection. In cases of especially complicated and protracted CSF infections, the flexible metal ventricular catheter is a promising device for treatment.     

Frameless stereotactic ventricular shunt placement for idiopathic intracranial hypertension

INTRODUCTION: Cerebrospinal fluid (CSF) shunting effectively reverses symptoms of idiopathic intracranial hypertension (IIH). Lumboperitoneal (LP) shunts have traditionally been used in patients with IIH due to a frequently undersized ventricular system. However, the advent of image-guided stereotaxis has enabled effective ventricular catheter placement in patients with IIH. We describe the first large series of frameless stereotactic ventriculoperitoneal (VP) shunting for patients with slit ventricles and IIH. METHODS: We describe the frameless stereotactic VP shunting technique for IIH in 32 procedures. Outcomes following shunt placement, time to shunt failure, and etiology of shunt failure are reported. RESULTS: A total of 21 patients underwent 32 ventricular shunting procedures (20 VP, 10 ventriculoatrial, 2 ventriculopleural). One hundred percent of shunts were successfully placed into slit ventricles, all requiring only one pass of the catheter under stereotactic guidance to achieve the desired location and CSF flow. There were no procedure-related complications and each ventricular catheter showed rapid egress of CSF. All (100%) patients experienced significant improvement of headache immediately after shunting. Ten percent of ventricular shunts failed at 3 months after insertion, 20% failed by 6 months, 50% failed by 12 months, and 60% failed by 24 months. Shunt revision was due to distal obstruction in 67%, overdrainage in 20%, and distal catheter migration or CSF leak in 6.5%. There were no shunt revisions due to proximal catheter obstruction or shunt infection. CONCLUSIONS: In our experience treating patients with IIH, frameless stereotactic ventricular CSF shunts were extremely effective at treating IIH-associated intractable headache, and continued to provide relief in nearly half of patients 2 years after shunting without many of the shunt-related complications that are seen with LP shunts. Placing ventricular shunts using image-guided stereotaxis in patients with IIH despite the absence of ventriculomegaly is an effective, safe treatment option.     

Technical Note: External Cerebrospinal Fluid (CSF) Drainage by Percutaneous Needle Punction in Newborn Children

Summary  External drainage of CSF in children is indicated in acute hydrocephalus e.g. after intraventricular bleeding or infection. In these cases the drainage has to remain in place until physiological CSF circulation is restored or an internal shunt can be inserted. External drainage is mostly performed using a silicon catheter connected to a plastic bag. An external CSF drainage left for several days in situ bears an increasing risk of bacterial infection. In these cases a metal needle minimizes the risk of ventriculitis.  For prevention of accompanying infection we implanted a Cytocan^R port needle with a 20 G diameter in 7 infants. The needle is easily inserted with low risk of complications. By its plastic top angulated at 90° to the needle the system can be fixed to the skin very safely by suture or tape.  With this system neither an implantation related intracerebral haemorrhage nor an accompanying ventriculitis was encountered. In two cases a pre-existing ventriculitis was cured by this needle drainage and antibiotic treatment. In five cases an acute hydrocephalus after intraventricular haemorrhage was drained by the port needle system.     

Management of intractable cancer pain: from intrathecal morphine to cell allograft

The durable effectiveness of intrathecal morphine administration is well established for the management of intractable cancer pain, after failure of systemic opioids, secondary to the persistence of non-reversible undesirable side effects. Many patients are referred to late in the disease course. This conservative method to control pain of malignant origin must not be reserved for last resort treatment for terminal patients. Intra-cerebro-ventricular morphine administration is a very effective and generally safe method for controlling intractable cancer pain. Because of the chronic implantation of an intra-ventricular catheter this method is somewhat invasive. Its indications remain a simple and effective alternative when the topography of nociceptive pain is diffuse or cephalic. In clinical practice, intrathecal and/or intra-cerebro-ventricular administration of opioids is limited by cost, the need for specialized maintenance and mechanical malfunctions if implantable drug delivery systems, or by the risk of bacterial contamination and ambulatory constraints when repeated daily injections via an intrathecal access port are used. To answer these limitations, cell therapy using intrathecal chromaffin cell allograft is a promising approach for the management of cancer pain refractory to traditional drug therapy and pain lesion surgery. The basic rationale and preclinical studies on experimental pain models have enabled starting prospective clinical trials. Prior to transplantation, handling and preparation of the chromaffin tissue is critical for allograft viability. The initial results of clinical trials with human chromaffin cell grafts from intractable cancer pain have reported long-lasting pain relief, in correlation with met-enkephalin release into the CSF. Convincing evidence will require controlled studies. The limitations of this innovative cell therapy and especially the lack of human adrenal gland availability point to the need for new sources of cells. Perspectives include xenogenic or engineered cell lines.     

Spontaneous bacterial peritonitis causing Serratia marcescens and Proteus mirabilis ventriculoperitoneal shunt infection. Case report

The authors report their experience treating a polymicrobial ventriculoperitoneal (VP) shunt infection in a developmentally delayed 21-year-old woman. Cerebrospinal fluid (CSF) cultures grew Serratia marcescens and Proteus mirabilis. On admission and throughout her hospitalization, results of physical examination of her abdomen were normal, and radiographic studies showed no evidence of bowel perforation or pseudocyst formation. Contrast-enhanced computed tomography of the abdomen revealed a small fluid collection. After a course of intravenous gentamicin and imipenem with cilastatin in conjunction with intrathecal gentamicin, the infection was resolved and the VP shunt was reimplanted. Although VP shunt infections are not uncommon, S. marcescens as a causative agent is exceedingly rare and potentially devastating. Only two previous cases of S. marcescens shunt infection have been reported in the literature. Authors reporting on S. marcescens infections in the central nervous system (CNS) have observed significant morbidity and death. Although more common, the presence of P. mirabilis in the CSF is still rare and highly suggestive of bowel perforation, which was absent in this patient. Spontaneous bacterial peritonitis was the likely source from which these bacteria gained entrance into the VP shunt system, eventually causing ventriculitis in this patient. The authors conclude that in light of the high morbidity associated with S. marcescens infection of the CNS, intrathecal administration of gentamicin should be strongly considered as part of first-line therapy for S. marcescens infections in VP shunts.     

External ventricular drainage for treatment of rapidly progressive posthemorrhagic hydrocephalus.

Twenty-seven newborn infants (birth weight, 1503 +/- 776 g; gestational age, 31 +/- 3 wk) (mean +/- standard deviation) with rapidly progressive posthemorrhagic hydrocephalus and increased intracranial pressure were treated by external ventricular drainage. The progression of hydrocephalus was arrested during the drainage period in each patient. The drainage was kept in place for 23 +/- 9 days, the longest drainage period being 48 days. In 16 of 23 surviving patients, progressive ventricular dilation recurred after removal of the drainage, requiring a definitive shunt implantation (nine ventriculoatrial, seven ventriculoperitoneal). For the remaining seven infants, no further therapy was necessary. Implantation of the permanent shunt was done days 28 to 88 (body weight, 2400 +/- 950 g). Bacterial cultures from cerebrospinal fluid and/or the tip of the ventriculostomy catheter were negative in 175 instances and positive in 11 instances (7 patients). No clinical or biochemical evidence of ventriculitis was noted. Four of the 27 patients died of causes unrelated to external ventricular drainage. Twenty-three infants survived. Seventeen of 23 survivors suffered from intraventricular hemorrhage Grade 3; in 7, neurological and developmental outcomes were classified as normal; 9 patients experienced mild to moderate paresis and/or mild to moderate developmental delay; and only 1 patient was severely retarded. Six patients with parenchymal lesions had severe motor and/or developmental handicaps. We consider external ventricular drainage an effective and safe therapy in newborn infants with rapidly progressive posthemorrhagic hydrocephalus and increased intracranial pressure. The ultimate outcome, however, depends mainly on the mode and the extent of the primary brain lesion.     

Immediate postoperative CT to assess the correct positioning of a ventricular catheter

Positioning of the ventricular catheter is safe using standard techniques, but in some cases there may be failure of a shunt because of incorrect placement. We carried out CT at the end of the surgical operation on 10 patients who had undergone cerebrospinal fluid shunting while still anaesthetized. In three cases a malpositioned catheter was detected. Immediate reoperation allowed readjustment of the ventricular catheter. Early postoperative CT appears to be useful for verifying correct placement.