Cerebrospinal fluid shunt survival and etiology of failures: a seven-year institutional experience

BACKGROUND: Innovations in shunt technology and neuroendoscopy have been increasingly applied to shunt management. However, the relative life span of shunts and the etiology of shunt failure have not been characterized recently. METHODS: We reviewed the records of all shunting procedures at our institution between January 1992 and December 1998. Independent predictors of shunt failure were analyzed via multivariate Cox regression analysis in 836 shunting procedures. Independent predictors of the etiology of failure (infection, proximal obstruction, distal malfunction) were analyzed via multivariate logistic regression analysis in the 383 shunts which failed. RESULTS: A total of 353 pediatric patients underwent 308 shunt placements and 528 revisions. The risk (hazard ratio; HR) of shunt failure decreased as a function of time in both primary placements and revised shunts. In failed shunts, the odds of infection decreased 4-fold per year of shunt function, while the odds of distal malfunction increased 1.45-fold per year. Increasing number of shunt revisions (HR 1.31, p < 0.05), decreasing patient age in years (HR 1.04, p < 0.001), gestational age <40 weeks (HR 2.15, p < 0.001) but not the etiology of hydrocephalus were associated with an increased risk of shunt failure. Revisions versus primary placements, Dandy-Walker cysts and gestational age <40 weeks were independently associated with proximal, distal and infectious causes of failure, respectively. CONCLUSIONS: The long-term shunt revision rates observed here are similar to those reported over the past 2 decades. Shunt life span remains poorer in shunt revisions and in younger patients. Patient characteristics may suggest a specific risk and mechanism of failure, aiding in the long-term management of shunted hydrocephalus.     

Ascites in ventriculoperitoneal shunt

Objective : To fetch out the factors responsible for ascites, following shunt CSF diversion in cases of intracarnial lesions. Four children developing ascites/abdominal psuedocyst following ventriculoperitoneal shunt were analyzed to see the factors responsible for such complication.Methods : Records of 4 cases developing ascites were studied retrospectively. These children developed ascites at 8 months, 6 months, 1 year and 1 year 2 months interval following their shunt installation.Resuts ;The primary etiology of hydrocephalus was demonstrated as thalamic glioblastoma, choroid plexus papillomas of third ventricle, post tubercular meningitis hydrocephalus and suprasellar craniopharyngioma.Conclusion: The proposed etiology of ascites in these cases was peritoneal metastasis from thalamic glioblastoma through ventriculoperitoneal shunt in first case, excessive production of CSF by choroid plexus papilloma in second, infection in the third case and craniopharyngioma causing excessive production of CSF in the fourth child. All the children were treated by reasonable laparotomy and fenestration of cyst along with the repositioning of shunt tip at another site.     

The gravity-assisted Paedi-Gav valve in the treatment of pediatric hydrocephalus

OBJECTIVE: A single-center, prospective, nonrandomized pilot study was performed to assess the Paedi-Gav gravity-assisted valve for the treatment of pediatric patients with hydrocephalus. METHODS: Participants were pediatric patients (age <16 years) who were candidates for a hydrocephalus shunt system that required a valve insertion at the time of enrollment. The primary outcome event was shunt malfunction; subclassified into shunt obstruction, shunt overdrainage, loculated ventricles, or infection. The shunt obstructions were further subclassified according to site. A total of 32 patients were enrolled onto the study, with 2 undergoing first shunt insertion after failed ventriculostomy and 30 undergoing shunt revisions. On average, the patients had had 3.3 shunt procedures prior to insertion of a Paedi-Gav valve. RESULTS: During a follow-up interval of minimum 52 weeks and a median of 24 months after the first implantation on-study, shunt revisions were required in 17 (53.1%) of the 32 patients. The 12-month shunt-survival rate without revision of any component was 53%, with a median shunt-survival time of 388 days. The most common reasons for shunt revision were shunt obstructions (12/17) and overdrainage (3/17). Shunt obstructions were caused by valve-related failures (9/12) and distal obstructions (3/12). CONCLUSION: Although the small number of patients enrolled in this study warrants cautious conclusions, the overall results are comparable to those reported for primary shunt insertions with conventional valves in pediatric patients with hydrocephalus. Although this study provides a rationale for examining the Paedi-Gav gravity-assisted shunt valve in a larger prospective randomized controlled trial, the shunt failure pattern, with a rather high frequency of valve-related failures, may indicate potential for further improvements in the valve design and/or manufacturing.     

Risk and risk factors for epilepsy in shunt-treated children with hydrocephalus

ObjectEpilepsy is a major comorbidity in children with hydrocephalus (HC) and has a serious impact on their developmental outcomes. There are variable influencing factors, thus the individual risk for developing epilepsy remains unclear. Our aim was to analyse risk factors for developing epilepsy in children with shunted HC.MethodsA retrospective, single-centre analysis of 361 patients with the diagnosis of HC was performed. Age at HC diagnosis, shunt treatment, development of epilepsy, epilepsy course, and the aetiology of HC were considered. The influence of shunt therapy, including its revisions and complications, on the development of epilepsy was investigated.ResultsOne-hundred forty-three patients with HC (n = 361) had a diagnosis of epilepsy (39.6%). The median age at the first manifestation of epilepsy was 300 days (range:1–6791; Q1:30, Q3: 1493). The probability of developing epilepsy after HC decreases with increasing age. The most significant influence on the development of epilepsy is that of the HC itself and its underlying aetiology (HR 5.9; 95%-CI [3–10.5]; p < 0.001). Among those, brain haemorrhage is associated with the highest risk for epilepsy (HR 7.9; 95%-CI [4.2–14.7]; p < 0.01), while shunt insertion has a lower influence (HR 1.5; 95%-CI [0.99; 2.38]; p = 0.06). The probability of epilepsy increases stepwise per shunt revision (HR 2.0; p = 0.03 after 3 or more revisions). Five hundred days after the development of HC, 20% of the children had a diagnosis of epilepsy. Shunt implantation at a younger age has no significant influence on the development of epilepsy nor does sex.ConclusionChildren with HC are at high risk for developing epilepsy. The development of epilepsy is correlated mainly with HC's underlying aetiology. The highest risk factor for the development of epilepsy seems to be brain haemorrhage. The age at shunt implantation appears to be unrelated to the development of epilepsy, while structural brain damage at a young age, shunt revisions and complications are independent risk factors. The onset of epilepsy is most likely to take place within the first 500 days after the diagnosis of HC.     

Uncommon manifestations of shunt infection

Shunt infection is one of the commonest and most troublesome cause of shunt failure. According to the etiology and clinical presentations it has been divided into external and internal types.Method : We hereby present four pediatric cases, who presented with atypical manifestations not coinciding with the above mentioned types of shunt infection. Three patients developed round, globular or diffuse fluctuant CSF filled swellings at the burr hole site, one of whom had involvement of the entire pericatheteral extent upto the abdomen.Result : The fourth child developed spontaneous expulsion of ventricular end of shunt tube through the dehiscent and infected chest wall incision site.Conclusion : First three of the above children were diagnosed as having internal type of shunt infections, while the fourth had mixed manifestations of external and internal type     

Reflections on shunt infection

The placement and revision of ventriculoperitoneal (VP) shunts remains a mainstay in the surgical treatment of hydrocephalus. While the North American infection rate averages nearly 8-10%, published infection rates for VP shunt infection below 1% have been reported. We retrospectively reviewed shunt operations by a single surgeon over 62 months to analyze the infection rate. In 62 months, we performed 526 shunt placements or revisions in patients up to 18 years of age. There were 7 shunt infections (1.33%). In 5 cases, the organism was Staphylococcus epidermidis, and a single shunt each was infected with Haemophilus influenzae and Staphylococcus aureus. Each infection was treated with external ventriculostomy drainage and intravenous antibiotics. The new shunt was placed at a new incision site after at least 5 days of sterile spinal fluid cultures. The mean follow-up among these patients after shunt insertion was 25 months. VP shunting remains the most common operation for hydrocephalus. Infections are linked with seizures, higher future risks of shunt infection and malfunction, and reduced IQ and school performance. Our infection rate during 62 months was limited to 1.33%. Uniform surgical technique, limited hardware and skin edge manipulation and double gloving may be important factors in limiting shunt infections.     

Comparison of total versus partial revision of initial ventriculoperitoneal shunt failures

BACKGROUND: Optimal surgical management of patients presenting with shunt failure in the age of neuroendoscopy remains complex. The value of replacing the entire shunt system as opposed to a single shunt component has not been assessed. METHODS: We reviewed the records of all pediatric patients who underwent their first shunt revision between January 1992 and December 1998. Patients with primary shunt failure attributed solely to proximal catheter obstruction or distal catheter obstruction were included for analysis. Shunt revisions were classified as total (entire shunt replaced) or partial (only malfunctioning component replaced). Kaplan-Meier (shunt survival curves) and log rank analysis were used to compare failure rates between partially and totally revised shunts according to the underlying diagnosis and failed shunt part. Significant differences in univariate analysis were confirmed with a multivariate proportional hazards regression model. RESULTS: 301 pediatric patients underwent primary shunt revision (183 total, 118 partial revisions). All shunts utilized distal slit peritoneal catheters. In shunt failures attributed to proximal obstruction, reutilization of the distal catheter was associated with a 57% increased risk of subsequent shunt failure (hazard ratio 1.57, 95% confidence interval 1.19-3.49). In shunt failures attributed to distal obstruction, subsequent shunt survival was not affected by reutilization of the proximal catheter (p = 0.581). When stratified according to the etiology of hydrocephalus, only patients with intraventricular hemorrhage (IVH) failed to demonstrate greater survival of totally revised shunts. CONCLUSIONS: In this series, in the setting of proximal shunt catheter obstruction, reutilizing the functional distal catheter was associated with an increase in subsequent shunt failure rates compared to revising the entire shunt system. Total revision was not associated with improved shunt survival in patients with IVH.     

A single-pass tunneling technique for CSF shunting procedures

Implantation of ventriculoperitoneal shunts in the precoronal position is generally accomplished using a retroauricular incision for subcutaneous tunneling. Retroauricular incisions can be associated with complications, including cerebrospinal fluid leak and shunt infection. We describe a technique for 'single-pass' shunt tunneling from frontal to abdominal incisions and our initial results in a consecutive, prospective series of 15 children (age 2 days to 5 years). Eleven patients presented with congenital hydrocephalus (including 5 with myelomeningocele and 3 with posthemorrhagic hydrocephalus) and 4 with hydrocephalus secondary to central nervous system (CNS) tumors. The average length of clinical follow-up was 6 months (range 1-13 months). There were no perioperative or long-term complications of the single-pass technique. Nine of the 11 patients with congenital hydrocephalus are currently well without any further medical or surgical intervention. Two underwent shunt revision for proximal obstruction, with an intact distal system. Three of the 4 patients with hydrocephalus secondary to CNS tumor suffered secondary shunt complications during periods of severe neutropenia resulting from chemotherapy (6 weeks to 6 months after shunt insertion). For primary ventriculoperitoneal shunt insertion in infants and young children, the single-pass tunneling technique is safe and avoids one source of complications.     

Seizures in children with meningomyelocele

The charts of 111 children with meningomyelocele were reviewed. Ninety-eight had shunted hydrocephalus. Twenty-five of 111 children (24 of 98 children with shunts) had seizures. Age at onset and type of seizure varied. Brain malformation (other than Arnold-Chiari), shunt infection, and perhaps number of shunt revisions were important risk factors in seizure development. The children with seizures were more likely to be developmentally delayed.     

Complications of cerebrospinal fluid shunts

In the period 1972–81, 572 hydrocephalic children were treated using the Upadhyaya shunt valve, One hundred and seventys-even of these patients needed a total of 350 shunt revisions. Indications for revisions were; shunt blockage 245 (70% of total revisions) shunt infections 40 (11.5%) catheter disconnections/fractures 19 (5.5%) and intvacranial hemorrhage 9 (2.5%). Intracranial bleeds were more commonly seen in hydrocephalus associated with tuberculous meningitis and were invariably fatal. Infrequent complications were CSF leak, shunt extrusion, valve incompetence, pulmonary hypertension and pleural effusion. Thirty-nine patients died. Overall results of the Upadhyayay shunt valve compare favourably with other reported series.     

Lumboperitoneal shunting as a treatment for slit ventricle syndrome

OBJECTIVE: Slit ventricle syndrome (SVS) has been described in hydrocephalus patients who continue to have shunt malfunction-like symptoms in the presence of a functioning shunt system and small ventricles on imaging studies. These symptoms usually present years after shunt placement or revision and can consist of headache, nausea and vomiting, lethargy and decreased cognitive skills. Treatments offered range from observation, medical therapy (migraine treatment) and shunt revision to subtemporal decompression or cranial vault expansion. We describe a subset of patients with SVS who were symptomatic with high intracranial pressure (ICP) as measured by sedated lumbar puncture and whose symptoms completely resolved after lumboperitoneal shunt (LPS) placement. METHODS: Seven patients with a diagnosis of SVS underwent lumboperitoneal shunting. The age at shunting ranged from 3 to 18 years. Most had undergone recent ventriculoperitoneal shunt (VPS) revisions for presentation of shunt malfunction-like symptoms. Despite this, all remained symptomatic and underwent a sedated lumbar puncture to measure opening pressure (OP). All had high OP in spite of a functional VPS and underwent LPS placement. RESULTS: All 7 patients had a prolonged period of overdrainage symptoms after lumboperitoneal shunting that resolved completely over several weeks. The initial etiology of hydrocephalus was reported to include trauma, aqueductal stenosis and intraventricular hemorrhage of prematurity. Two patients required revision of their LPS, after which their symptoms again resolved. CONCLUSION: In a certain subset of patients with SVS who are symptomatic from increased ICP, placement of an LPS is an effective treatment option. It appears that this subgroup of patients previously treated with ventriculoperitoneal shunting behave in a fashion similar to pseudotumor cerebri patients and respond well to lumboperitoneal shunting.     

儿童屎肠球菌脑膜炎的临床特征分析

目的 总结屎肠球菌脑膜炎患儿的临床特点,以期提高临床诊治水平。方法 对9例屎肠球菌脑膜炎患儿进行临床资料分析。结果 9例患儿均经血液或脑脊液或PICC端培养出屎肠球菌,其中6例（67%）为新生儿,2例（22%）为6个月以内婴儿,1例（11%）为3岁4个月幼儿。56%的患儿起病前存在致病高危因素：肠道感染、脑积水术后安置引流管,以及颅骨骨折、导管相关性感染和母亲围产期感染。以发热、反应差为主要表现,22%的患儿出现抽搐,均无脑膜刺激征及意识障碍。血常规白细胞总数及CRP正常或升高;脑脊液有核细胞正常或轻度升高,蛋白明显升高,糖降低。药敏均提示对万古霉素敏感,且万古霉素治疗有效,1例出现脑积水并发症。结论 屎肠球菌脑膜炎主要见于新生儿及婴儿,存在致病高危因素的比例高,临床特征不典型,对万古霉素敏感。     

Mental health status of runaway adolescents

There are 47.22 million homeless and runaway adolescents roaming on the streets of our country (Voluntary Health Association of India — VHAI) of which one lakh are in Delhi. Very little is known about them, their needs or their experiences.Objective: (1) To assess the psychological problems amongst the runaway adolescent boys. (2) To determine possible risk factors.Methods: This study was cross-sectional in design and done at a child observation home for boys in Delhi. All runaway boys aged 10 to 16 years of age were included in the study. The study was conducted from 15^th June to 15^th July 2001. A comprehensive schedule consisting of five parts, viz identification data, hopelessness scale for children by Kazdin, Beck depression inventory, Psychological survey questionnaire and RUTTER-B2 scale were used to assess various mental health problems.Results: 20.7% of children were found to have high hopelessness and 8% of children had depression. 2% of children revealed that they had attempted suicide at any point of time in life. Among children with high hopelessness, 3.2% had ever attempted suicide. 8.3% of the depressed children gave history of suicidal attempts. 38% of children gave history of physical abuse, 14.6% of sexual abuse and a large number reported substance abuse. 69.33% were found to have behavioral problems (i.e. scored above the recommended cut off score of 9). 81% of children had antisocial behavior, 7.8% were neurotic and 10.5% remained undifferentiated.Conclusion: Runaway adolescents suffer from a wide array of mental health problems and there is a need for a broad based psychosocial intervention programme.     

Czynniki ryzyka,etiologia i wyniki leczenia zakażeń Candida sp. u noworodków hospitalizowanych w oddziale intensywnej terapii

BackgroundCandida infection develop in 6–18% of neonates with mortality rate between 22–32%.AimA 6-years retrospective analysis of mobility rate, risk factors and results of the treatment of Candida infections in newborns hospitalized in NICU.MaterialThe study comprised 80 (46 boys, 34 girls) newborns, among them 27 with ELBW, 20 with BW between 1001–1500 g, 16 with BW 1501–2500 g i 17 weighing >2500 g. Fluconazole prophylaxis was applied from third day of life in all newborns.Results113 Candida infections were noted in 80 newborns, among them 10 in first week of life, 28 between 8^th and 15^th day, 33 between 16–30^th and 42 > 30^th day of life. Eighteen types of Candida sp. were isolated, most often C. albicans (275), C. sake (25%) and C. lusitaniae (18%). Died 14 (17,5%) infants. Significant relationship between death of newborns and their fetal maturity and number of Candida infections was stated. Any significant relationship between birth weight, gender, clinical state after birth, time of hospitalization of newborns and results of the treatment was noted.Conclusions1. In newborns treated in the NICU, despite fluconazole prophylaxis, late-onset Candida infections are noted. 2. C. albicans, C. sake and C. lusitaniae dominate in etiology of neonatal invasive Candida infection. 3. Fetal maturity and number of Candida infections have significant prognostic values in newborns with Candida infection.     

Cerebrospinal fluid shunt infections in children

Forty-six episodes of cerebrospinal fluid shunt infections developed in 32 patients undergoing cerebrospinal fluid shunt operations during a 13-year period (1972 to 1984). The infection rate was 21%/operative procedure and 33%/patient. The shunt infection rate in revisions of infected shunts was 52%, a rate significantly larger than that in revisions of noninfected shunts (11%). Eight patients (25%) of the initially infected patients had more than one infectious episode. Predominating pathogens in patients who had shunt revisions included coagulase-negative staphylococci in 8 of 15 episodes (4 patients). Coagulase-negative staphylococci accounted for 28% and coagulase-positive staphylococci for 14% of the initial infectious episodes. Risk factors for development of shunt infection included age younger than 3 years, a previously infected shunt and surgery to revise the infected shunt. Therapy of infected shunts with antibiotics alone or with antibiotics plus an operative shunt revision resulted in similar success rates.     

Respiratory morbidity in children with congenital heart disease

ObjectiveTo evaluate the respiratory outcome in children with congenital heart disease (CHD), considering recent management procedures and the CHD pathophysiology.Design and SettingClinical and functional respiratory outcome were evaluated in 8-year-old children with isolated CHD followed up from birth in the prospective population-based EPICARD cohort.PatientsChildren were assigned to two groups, based on the pathophysiology of the CHD: CHDs with left-to-right shunt (n = 212) and CHDs with right outflow tract obstruction (n = 113).ResultsCurrent wheezing episodes were observed in 15% of the children with isolated CHD and left-to-right shunt, and 11% of the children with isolated CHD and right outflow tract obstruction (not significant). Total lung capacity (TLC) was the only respiratory function parameter that significantly differed between the two groups. It was lower in children with left-to-right shunt (88.72 ± 0.65% predicted) than in those with right outflow tract obstruction (91.84 ± 0.96, p = 0.006). In multivariate analysis, CHD with left-to-right shunt (coeff. [95% CI]: -3.17 [-5.45; -0.89]) and surgery before the age of 2 months (-6.52 [-10.90; -2.15]) were identified as independent factors associated with significantly lower TLC values.ConclusionLower TLC remains a long-term complication in CHD, particularly in cases with left-to-right shunt and in patients requiring early repair. These findings suggest that an increase in pulmonary blood flow may directly impair lung development.     

Reversible transinsular herniation of the lateral ventricle

We present a 7-year-old boy, with a history of neonatal intraventricular hemorrhage, leading to hydrocephalus with multiple shunt revisions. The current presentation of shunt failure and resultant hydrocephalus was complicated by herniation of the trigone of the lateral ventricle into the posterior fossa. Despite the dramatic radiological appearance, this herniation of the lateral ventricle was not accompanied by any additional clinical signs or symptoms other than those usually attributed to hydrocephalus. Following successful shunt revision, the patient returned to his baseline clinically with the trigone reverting back to its normal position. We also present a second companion case.     

Congenital Hydrocephalus: Role of Transplacental Myxovirus Infection

The definite etiology in most cases of congenital hydrocephalus still remains unknown. Many studies have been reported on the experimental hydrocephalus induced by viral infection other than TORCH (Toxoplasma, Other agents, Rubella virus, Cytomegalovirus and Herpes simplex type 1 and 2 viruses). Above all mumps virus induces a high frequency of hydrocephalus. Several pediatric cases of hydrocephalus after mumps virus infection have been reported. These cases are thought to be caused by ependymitis due to mumps virus infection. Clinical cases of congenital hydrocephalus possibly caused by intrauterine mumps or influenza virus infection are also accumulating. The definitive evidence of a teratogenic potential for mumps and influenza virus, however, has been obscure yet. Our experimental studies demonstrated that mumps and parainfluenza virus type 3 could induce hydrocephalus by destructive ependymal infection in suckling hamsters. However, the transplacental infection of these viruses was rare. These results show that myxoviruses such as mumps and parainfluenza virus have a strong affinity to ependymal cells, and then they cause resultant ependymal destruction. We suggest that when the placenta is impaired so severely that these viruses are able to pass through the placental barrier, maternal infection would cause the hydrocephalus to the infant.     

Neurosurgical management of hydrocephalus by a general surgeon in an extremely low resource setting: initial experience in North Kivu province of Eastern Democratic Republic of Congo

Purpose

Evaluate the management of hydrocephalus in pediatric patients in the Eastern Democratic Republic of Congo by a general surgeon.

Methods

Retrospective review of a single institution in the province of North Kivu. Patient charts and surgical notes were reviewed from 2003 to 2016.

Results

116 procedures were performed for an average of 8.9 per year. 51.7% of surgeries were on female patients with an average age of 13.6?±?22.7. The average distance traveled from home to hospital was 153.7 km but ranged from 5 to 1420 km. The majority of hydrocephalus was due to neonatal sepsis (57%); 33.6% were classified as congenital; 9.5% of cases followed myelomeningocele closure. 97.4% had a ventriculoperitoneal (VP) shunt placed. Endoscopic third ventriculostomy combined choroid plexus cauterization (ETV/CPC) was performed in 2.5% of patients. Shunt infection occurred in 9.5% of patients, shunt dysfunction or obstruction in 5.2% and shunt exteriorization in 1.7%; no complications occurred in patients who underwent ETV/CPC.

Conclusion

VP shunt is the predominant management for hydrocephalus in this environment with increasing use of ETV/CPC. Further research is needed to evaluate variability by etiology, short and long-term outcomes of procedures performed by neurosurgeons and general surgeons, and regional epidemiologic variability.

     

Does cerebral perfusion improve following CSF diversion in pediatric hydrocephalus? A prospective study using 99mTc ECD single photon emission computed tomography

AIMS AND OBJECTIVES: To study regional cerebral perfusion before and after ventriculoperitoneal shunt placement in children with hydrocephalus, using (99m)Tc ECD single photon emission computed tomography (SPECT). MATERIALS AND METHODS: 17 consecutive children (less than 16 years) with hydrocephalus due to various causes, who were planned for ventriculoperitoneal shunt, were included in this prospective study. Brain SPECT using (99m)Tc ECD was performed pre- and postoperatively and changes in cerebral perfusion were compared with the change in ventricular size (assessed using Evan's ratio). OBSERVATIONS: There were 11 males and 6 females with a median age of 24 months. Nine children were up to 2 years of age and the mean duration of symptoms was 6 months. The cause of hydrocephalus was congenital in 10, secondary to tumor in 5 and as sequelae of infection in 2 children. Fourteen children (82%) showed improvement in cerebral perfusion following shunting. Of these, 12 also had a concomitant decrease in ventricular size postoperatively. RESULTS: On logistic regression analysis, none of the factors analyzed, i.e. age, duration of symptoms, etiology of hydrocephalus and decrease in ventricular size, were found to predict improvement of cerebral perfusion following shunting. CONCLUSIONS: Cerebral perfusion improves in the majority of the children following CSF diversionary procedures, and contrary to the common belief, duration of hydrocephalus and decreased ventricular size do not influence this improvement in cerebral perfusion. SPECT can therefore prove to be a valuable tool for objective assessment of improvement in cerebral perfusion in children with hydrocephalus secondary to various etiologies following surgical or medical interventions.