Persistent hydrocephalus due to postural activation of a ventricular shunt anti-gravity device

The ever present need to balance over drainage with under drainage in hydrocephalus has required innovations including adjustable valves with antigravity devices. These are activated in the vertical position to prevent siphoning. We describe a group of bedridden patients who presented with unexplained under drainage caused by activation of antigravity shunt components produced by peculiar head/body position.Retrospective single centre case series of hydrocephalus patients, treated with ventriculo-peritoneal (VP) shunt insertion between April 2014 – February 2016. These patients presented with clinical and radiological under drainage syndrome. Medical notes were reviewed for clinical picture and outcome. Radiological studies were reviewed assessing shunt placement and ventricular size.Seven patients presented with clinical and radiological under drainage syndrome. A consistent posturing of long term hyper-flexion of the neck whilst lying supine was observed. All patients had similar shunt construct (adjustable Miethke ProGAV valve and shunt assistant anti-gravity component). In each of those patients a hypothesis was formulated that neck flexion was activating the shunt assistance anti-gravity component in supine position. Five patients underwent shunt revision surgery removing the shunt assistant device from the cranium and adding an anti-gravity component to the shunt system at the chest. One had the shunt assistant completely removed and one patient was managed conservatively with mobilisation. All patients had clinical and radiological improvement.Antigravity shunt components implanted cranially in bedridden hydrocephalus patients will produce underdrainage due to head flexion induced anti-gravity device activation. In these patients, anti-gravity devices should be placed at the chest. Alternatively, special nursing attention should be paid to head-trunk angle.     

Shunt-related headaches: the slit ventricle syndromes

Purpose The purpose of this work is to review the pathophysiology and treatment of severe headache disorders in patients having a shunt for hydrocephalus. Materials and methods The literature on the management of the slit ventricle syndrome is reviewed as well as an assessment of personal experiences over a 30-year period in the management of severe headache disorders in shunted patients. Results If the slit ventricle syndrome is defined as severe, life-modifying headaches in patients with shunts and normal or smaller than normal ventricles with ventricular shunts for the treatment of hydrocephalus, there are five different pathophysiologies that are involved in the process. These pathologies are defined by intracranial pressure measurement as severe intracranial hypotension analogous to spinal headaches, intermittent obstruction of the ventricular catheter, intracranial hypertension with small ventricles and a failed shunt (normal volume hydrocephalus), intracranial hypertension with a working shunt (cephalocranial hypertension), and shunt-related migraine. The treatment of these conditions and identifying patients with each condition are facilitated by attempting to remove the shunt. Conclusions Following the analysis of attempts to remove shunts, there are three possible outcomes. In about a quarter of patients, the shunt can be removed without having to be replaced. This is most common in patients treated in infancy for post-hemorrhagic hydrocephalus or patients shunted early after or before brain tumor surgery. Another half of patients have increased intracranial pressure and enlarged ventricles. In these patients, there is an 80% success rate for endoscopic third ventriculostomy. Finally, the most severe form of the slit ventricle syndrome involves intracranial hypertension without ventriculomegaly, which is managed optimally by shunt strategies that emphasize drainage of the cortical subarachnoid space such as lumbo-peritoneal shunts or shunts that include cisterna magna catheters.     

Salvaging the “lost peritoneum” after ventriculoatrial shunt failures

Objective Placement of a ventriculoperitoneal (VP) shunt is the long-standing treatment of choice for hydrocephalus. However, in many patients with repeated distal failures, ventriculoatrial (VA) shunts are placed. Should the VA shunt fail, finding appropriate distal sites is often difficult. Materials and methods We identified six patients, over a 3-year period, in whom conversion of VA to VP shunt was successfully performed with the aid of diagnostic laparoscopy or laparotomy. There were no ensuing shunt failures during the follow-up period (mean 1.5 years). Conclusion Because of the benefits of VP over VA shunting, every effort should be made to preserve the peritoneum as the target for the distal catheter. Laparotomy/laparoscopy is useful in locating suitable peritoneal targets when converting to VP shunt after VA shunt failure, or as a final effort before VA shunt conversion.     

脑积水脑室-腹腔分流术的并发症及处理对策

目的 探讨脑室-腹腔(VP)分流术后并发症的诊断及其防治方法.方法 回顾性分析l86 例VP 分流术后发生并发症的18 例临床资料.结果 186 例患者术后并发症发生率为9.6% (18 /186),其中颅内感染6 例,腹部感染1 例,皮下隧道感染1 例,分流管堵塞4 例,分流过度2 例,分流不足4 例.结论 预防V...     

Long-term outcome of hydrocephalus management in myelomeningoceles

BACKGROUND: The cerebrospinal fluid (CSF) shunt remains an important ongoing management problem in myelomeningocele (MMC) patients. We reviewed the long-term shunt treatment outcome in a prospectively followed group of MMC patients from a single institution. METHOD: Patients prospectively entered into a hydrocephalus database with a diagnosis of MMC from the years 1987 to 1996 were selected. All data was verified from the medical records and additional details about the shunt surgery were collected. The outcome of shunt failure was categorized as shunt obstruction, shunt infection, presence of loculated ventricles, overdrainage, and other. All deaths were recorded and causation identified. Univariate analysis for shunt failure risk factors was accomplished using Log rank statistics. Multivariable analysis was performed for each repeated failure level using a conditional Cox regression model. RESULTS: One hundred and twenty (64%) out of 189 MMC patients experienced a first shunt failure with a median time of 303 days; 29 (24%) of the failures were due to shunt infection (the procedure infection rate being 15%). Sixty-one patients experienced a second shunt failure, 38 a third and 36 had four or more. Multivariable analysis of risk factors failed to demonstrate any clear risk factors for either first or subsequent shunt failure. Fifteen patients died, 13 from either shunt or Chiari 1 complications. CONCLUSION: Shunt complications remain an important cause of morbidity and mortality in MMC patients, particularly shunt infection.     

脑室心房分流术在脑室腹腔分流术难治性脑积水中的临床应用

目的分析难治性脑积水患者反复脑室腹腔分流术(VP)失败后改脑室心房分流术(VA)的临床治疗情况。方法收集我院收治的反复VP失败后改行VA的脑积水患者,回顾分析其治疗情况和预后;同时利用logistic回归分析年龄、性别、术前是否感染、术前手术次数、以及术侧与VA手术的成败是否相关。结果共入选46例患者,其中首次VA成功的占73.9%(34/46),首次失败的占26.1%(12/46),失败原因包括感染、静脉血栓、分流管心房端移位等。logestic回归分析显示年龄、性别、术前是否感染、术前手术次数、术侧与首次VA手术的成败不相关。首次失败后的有12例患者,经过重新手术后成功的58.3%(7/12);经再手术仍然失败并且最终死亡的占41.7(5/12),原因为感染和肺动脉高压。结论 VA治疗反复VP失败的脑积水患者仍然具有较高的成功率;但首次VA失败后,再失败的机率高,预后差。     

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.     

难治性脑积水分流管堵塞伴感染的神经内镜治疗

目的探讨神经内镜三脑室造漏术（NTV）在脑积水分流术后堵管并颅内严重感染病例中的应用。方法回顾性分析了神经内镜下三脑室底造瘘治疗脑积水V-P分流术后堵管并严重颅内感染的患者8例。对治疗时机、手术技巧及术后治疗和近期疗效进行评估。结果8例患者的临床症状及术后影像学检查均有不同程度的好转，无并发症出现。结论神经内镜在治疗脑积水分流术后堵管并颅内严重感染是一种有效的微创手术。     

Subdural-peritoneal shunt: one-piece design with a large flushing device

In an effort to maximize the effectiveness of subdural-peritoneal shunting for the treatment of chronic subdural hematoma in infants, the author developed a new shunt system. The characteristics of this shunt include a large-caliber catheter, a very low pressure slit valve, and a one-piece design with a large flushing device. This shunt is particularly useful for patients without increased intracranial pressure, who are usually refractory to treatment using a conventional ventriculoperitoneal shunt system.     

Experience with ventriculo-pleural shunts

Ventriculo-pleural shunting for the management of hydrocephalus was initially introduced by Ransohoff in 1954. However, because of the reported cases of pleural effusion with this procedure, the operation has not achieved popularity in the management of hydrocephalus. In the course of a review of 1,500 patients with hydrocephalus treated at the Hospital for Sick Children over the years 1960-1981, we encountered 59 patients who had been treated with a ventriculo-pleural shunt during the years 1971-1981. The commonest reason for insertion of the ventriculo-pleural shunt was a preexisting infected ventriculo-peritoneal shunt. 12 of the 59 patients developed pleural effusions, and 6 of these 12 patients were under 11 months of age. The incorporation of an antisiphon device in the shunting system seemed to decrease the possibility of a pleural effusion. 23 of the 59 patients continue to function on their inserted ventriculo-pleural shunt, and in 9 of these the shunts have been functioning for over 5 years. Ventriculo-pleural shunting seems to be a safe and simple form of diversionary CSF bypass. The risk of pleural effusion seems to be highest in the infant, but can occur at any age. However, even in the infant the ventriculo-pleural shunt provides a good temporary site for diversion of CSF when the peritoneal cavity is contaminated or hazardous to shunt function. Ventriculo-pleural shunting provides a valuable alternative for the management of hydrocephalus in those patients where the heart or the peritoneal cavity are unsuitable sites.     

Shunt dysfunction due to calcification of a ventriculo-peritoneal shunt: a case report.

Calcification and related dysfunction of ventriculo-peritoneal shunts are rare events in neurosurgical practice. Shunt calcification causes shunt dysfunction in two ways, namely disconnection and obstruction.We present a 16-year-old girl with shunt malfunction due to disconnection secondary to calcification. The shunt tubing fractured during attempted removal and some of the remaining components, including the ventricular catheter, had to be left in situ. The shunt was revised and the patients symptoms resolved. Replacement of the calcified and perished shunt components with a new shunt is essential. Aggressive surgical manipulation for removal of the remaining shunt components is not advisable as this may increase morbidity and mortality.     

Prolonged exposure to antibiotic-impregnated shunt catheters does not increase incidence of late shunt infections

Objective Antibiotic-impregnated shunt (AIS) systems have been designed to prevent the colonization of shunt components by skin flora that occurs at surgery. Although such systems may decrease the incidence of early shunt infections (those occurring within 6 months of shunt placement), it is unclear if such exposure to prolonged antibiotics leads to an increased incidence or virulence of late shunt infections (those occurring later than 6 months after shunt placement). In this study, the authors evaluate the incidence of late shunt infection after the introduction of an AIS system in a pediatric hydrocephalus population. Materials and methods We prospectively reviewed all pediatric patients undergoing antibiotic-impregnated CSF shunt insertion or shunt revision operations at our institution for the 33 month period between October 1, 2002 and June 31, 2005. All shunt-related complications, including shunt infection, were evaluated in those patients with later than 6 months of follow-up. Results A total of 153 pediatric patients (between 1 and 21 years of age) underwent 262 shunting procedures involving the use of antibiotic-impregnated catheters. All patients were followed-up for later than 6 months with a mean follow-up of 21.7 months (range 13–46 months). Ten patients (3.82%) experienced an early shunt infection within the 6-month follow-up period. No patients experienced a late shunt infection. Conclusion Although concern exists that AIS systems may delay shunt infections or even increase the rate or virulence of such infections, introduction of such catheters into a pediatric hydrocephalus cohort does not significantly increase incidence of late CSF shunt infection compared to historic controls.     

How should primary aqueductal stenosis in adults be treated? – A review

In 10% of adult patients with hydrocephalus, the cause is because of aqueductal stenosis (AS), causing enlargement of the lateral and third ventricles. There are currently two alternate forms of surgical treatment for AS; shunt surgery and ventriculostomy. Shunt surgery is associated with high complication rates and many patients need revisions, but the effectiveness is high. Endoscopic third ventriculostomy (ETV), re-establishing a physiological route of CSF dynamics, has become the treatment of choice for AS in most neurosurgical centers. ETV has fewer complications and revisions are rare, but some patients need shunt surgery to improve despite a patent ventriculostomy. There are today no common criteria for patient selection to either ETV or ventriculo-peritoneal shunt surgery.     

The usefulness of lumbar infusion test in the evaluation of the intracranial volume pressure compensation in hydrocephalus before and after shunt insertion]

The analysis is presented of selected parameters of the lumbar infusion tests performed in hydrocephalic patients before and after shunt. In properly functioning shunt (50 cases) the mean values of the variables are on an average twice lower than before shunt. In patients with shunt malfunction (surgically verified in 7 out of 10 suspected cases) the values of the parameters are similar before and after shunt and are statistically significant. Lumbar infusion test is proved very useful in the detection of shunt malfunction, particularly when it is possible to compare it to the test performed before shunt.     

Monitoring of somatosensory evoked responses during carotid endarterectomy

During carotid endarterectomy (CEA), we monitored somatosensory evoked responses (SERs) ipsilaterally over the scalp following stimulation of the contralateral median nerve at the wrist. Thirty-eight CEAs in 36 patients were studied. Of the 10 CEAs performed with patients under general anesthesia, three involved marked changes in SERs, reversed by shunt insertion. The remaining 28 CEAs were done with patients under local anesthesia. The SERs remained stable during an average clamp time of 30 minutes in all except one patient, in whom SER changes developed within a minute of clamping; the changes were reversed by shunt placement. Four of the 38 CEAs required a shunt based on SER changes, although measurement of stump pressure (less than 50 mm Hg) would have indicated the necessity of a shunt in eight additional operations. We concluded that SERs are useful in signaling cerebral ischemia and the need for a shunt during CEA.     

A critical analysis of 'normal' radionucleotide shuntograms in patients subsequently requiring surgery

BACKGROUND: Shuntograms are performed when patients present with symptoms suggestive of, but inconclusive for, shunt malfunction, without confirmatory radiological evidence. METHODS: Shuntograms over the past 3.5 years were reviewed. Patient records were reviewed for revision in proximity to a negative (normal) study. RESULTS: One hundred and fifteen out of 149 tests were negative. Thirty-four surgeries (in 31 patients) occurred subsequent to a negative shuntogram. In 18 out of 34 revisions the shunt was functional: 13 surgeries were for overdrainage, 4 were for unrelated reasons with shunt function confirmed incidentally and 1 was an exploration for cognitive deterioration. In 16 cases (13 patients) the shunt was not functional: 12 had proximal catheter occlusion in which, on subsequent review, there was no ventricular reflux present and the remaining had distal malfunctions. CONCLUSIONS: The false negative rate for shuntograms was 16 out of 115 (14%) with proximal occlusion most common. This estimate of the predictive value of a normal flow study may influence the decision to revise a shunt.     

脑室腹腔分流术治疗成人外伤性脑积水分流管的选择

目的探讨脑室一腹腔分流术治疗成人外伤性脑积水时分流管的选择。方法回顾性分析2010年1月至2012年12月脑室-腹腔分流术治疗48例成人外伤性脑积水患者的临床资料。选择抗虹吸分流管的42例,选择非抗虹吸分流管的6例;选择可调压分流阀的28例,选择固定压力分流阀的20例。结果术后1周临床症状缓解37例（77．1％,37／48）症状缓解不明显11例（22．9％,11／48）。头颅CT或MRI复查示分流管脑室端位于脑室内,脑室缩小。术后随访2～38个月,重新再调整阀门压力8例,每例调整2～4次。结论脑室一腹腔分流术仍是治疗成人外伤性脑积水的首选方式,有条件的患者尽量选择可调压抗虹吸分流管,对于不愿选择可调压分流管的患者,可选择低压或中压分流管。     

Measurement of peak CSF flow velocity at cerebral aqueduct, before and after lumbar CSF drainage, by use of phase-contrast MRI: utility in the management of idiopathic normal pressure hydrocephalus

OBJECTIVE: Since it was first described, normal pressure hydrocephalus (NPH) and its treatment by means of cerebrospinal fluid (CSF) shunting have been the focus of much investigation. Whatever be the cause of NPH, it has been hypothesized that in this disease there occurs decreased arterial expansion and an increased brain expansion leading to increased transmantle pressure. We cannot measure the latter, but fortunately the effect of these changes (increased peak flow velocity through the aqueduct) can be quantified with cine phase-contrast magnetic resonance imaging (MRI). This investigation was thus undertaken to characterize and measure CSF peak flow velocity at the level of the aqueduct, before and after lumbar CSF drainage, by means of a phase-contrast cine MRI and determine its role in selecting cases for shunt surgery. PATIENTS AND METHODS: 37 patients with clinically suspected NPH were included in the study. Changes in the hyperdynamic peak CSF flow velocity with 50 ml lumbar CSF drainage (mimicking shunt) were evaluated in them for considering shunt surgery. RESULTS: 14 out of 15 patients who were recommended for shunt surgery, based on changes peak flow velocity after lumbar CSF drainage, improved after shunt surgery. None of the cases which were not recommended for shunt surgery, based on changes in CSF peak flow velocity after lumbar CSF drainage, improved after shunt surgery (2 out of 22 cases). CONCLUSION: The study concluded that the phase-contrast MR imaging, done before and after CSF drainage, is a sensitive method to support the clinical diagnosis of normal pressure hydrocephalus, selecting patients of NPH who are likely to benefit from shunt surgery, and to select patients of NPH who are not likely to benefit from shunt surgery.     

一种诊断脑室-腹腔分流装置梗阻的方法

目的 介绍一种诊断脑室腹腔分流装置梗阻的方法。方法 选择2014年8月至2018年3月收治的腹腔分流术后病人32例，其中分流装置梗阻16例（梗阻组），分流装置通畅16例（对照组）。病人先平躺1 h后改坐位，将0.1 ml 5%葡萄糖溶液注射入贮液囊，20 min后抽0.1 ml，用生理盐水将其稀释1倍后应用血糖仪检测葡萄糖浓度。结果 对照组贮液囊内葡萄糖浓度[（6.6±1.6）mmol/L]较梗阻组[（31.9±2.8）mmol/L]明显下降（P<0.05）。梗阻组病人入院后均行脑室-腹腔分流管调整术，手术证实分流装置梗阻，术后病人颅内压增高症状消失，术后3 d复查头颅CT结果显示脑室体积较术前减小11例，无明显变化5例。结论 此方法可检测分流管内脑脊液的流动情况，为诊断分流装置梗阻提供一种新的方法。     

Dysfunction of Holter Mini Elliptical Valves Caused by Minor Head Trauma

Two patients with implanted shunts suffered three disconnections of the shunt catheters from the valve chamber as a result of minor head trauma. In all instances a Holter Mini Elliptical valve had been used. The design of this valve may facilitate the kind of shunt dysfunction described. Suggestions are made for small changes in the shunt design or surgical procedures to obviate the vulnerability of the shunt to minor trauma.