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.     

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.     

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.     

The delta valve: how does its clinical performance compare with two other pressure differential valves without antisiphon control?

OBJECTIVE: The Delta valve is a pressure differential valve with a siphon control device. The valve mechanism is normally closed, but is designed to open in response to positive ventricular pressure, thereby avoiding overdrainage of cerebrospinal fluid (CSF). As a result, the incidence of subdural fluid collections as well as postural symptoms is purportedly reduced. In addition, the valve might reduce the number of obstructions as there would be no negative pressure sucking tissue and debris into the shunt system. In order to assess whether use of the Delta valve reduced the number of shunt-related problems as compared with two other pressure differential valves without an antisiphon component, we performed a retrospective review of all children undergoing CSF diversion procedures at our institution. METHODS: We reviewed the charts of 1, 193 patients. Cases included 2,325 ventriculoperitoneal (V-P) shunt insertions or revisions from January 1, 1985, to December 31, 1994, performed at our institution. The Delta valve and two pressure differential valves without antisiphon function were exclusively inserted during the following time periods: Holter-Hausner (H-H): January 1, 1985, to August, 1987; Heyer-Schulte (H-S): August, 1987, to June, 1991, and Delta: June, 1991, to December 31, 1994. RESULTS: Of the cases reviewed, 475 patients underwent insertion of a V-P shunt at the Childrens Hospital of Los Angeles and had a total of 686 shunt operations. Median follow-up was 3 years and ranged up to 10 years. Kaplan-Meier analysis documented that 67% of H-H, 71% of H-S and 70% of the Delta valves were functioning at 1-year follow-up. At 2-year follow-up, 66% of H-H, 64% of H-S and 65% of the Delta valves were functioning. The difference was not statistically significant. The occurrence rate for symptomatic subdural fluid collections was 0.7% (1/130) for H-H, 2.2% (3/139) for H-S and 1.0% (2/206) for the Delta valve (p = 0.52). The combined breakage/obstruction rate for the series was 7.7% (10/130) for H-H, 2.9% (4/139) for H-S and 4.9% (10/206) for the Delta valve (p = 0.19). No Delta valves malfunctioned secondary to fibrous capsule affecting the antisiphon device. CONCLUSIONS: In conclusion, it appears that performance of the Delta valve was not significantly different from the H-H and H-S valves, two valves without an antisiphon device. There was no significant difference in the occurrence of symptomatic subdural fluid collections based upon valve type, or in the combined valve breakage/obstruction rates based upon valve type.     

Shunt revisions in children--can they be avoided? Experiences from a population-based study

Background: Shunt failure is by far the most frequent problem in children with shunts, and most of them will experience this condition at some point in their lives. In order to identify causes of shunt failure, and to compare multi-component and one-piece shunt systems, we analyzed retrospectively all pediatric shunt procedures in our Department during an 11-year period. The study does not deal with shunt infections. Methods: We reviewed the records of all pediatric shunting procedures between January 1986 and December 1996. Results: The study included 161 children operated for hydrocephalus with a total of 431 procedures. The procedures included 124 (29%) primary insertions, 10 (2%) reinsertions and 297 (69%) revisions; 206 (69%) of the revisions were due to shunt failures, of which 74 (36%) were caused by the failure of the surgical technique (misplaced ventricular catheters, disconnected shunts, or misplaced peritoneal catheters). Conclusions: Improvement of the surgical technique may reduce the incidence of shunt failures and revisions. The results obtained in a small department like ours do not seem to differ substantially from those obtained in more specialized departments with a larger patient group. Practical measures that may reduce the risk of shunt failures are suggested.     

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.     

Abdominal pseudocyst: predisposing factors and treatment algorithm

Abdominal pseudocyst (APC) is an uncommon complication of ventriculoperitoneal shunts. Various predisposing factors have been attributed to it, including the presence of infection and multiple shunt revisions. We reviewed the records of shunt revisions performed over a 20-year period. During that time, 64 cases of APC were found in 36 patients. The records were then reviewed for the presence of infection, history of necrotizing enterocolitis, prior abdominal surgery, and treatment performed. Of the cases of APC, 46 were primary and 18 were recurrent. A history of prior abdominal surgery other than shunt revision was found in 47% of patients and a history of necrotizing enterocolitis was found in 19% of patients. The average number of prior shunt revisions was 4.1 per patient. Shunt infection as defined by positive cultures of either cerebrospinal fluid or abdominal fluid was present in only 23% of cases of APC. A history of prior shunt infection was present in 30% of patients. Infection was treated by shunt removal, external ventricular drainage, and appropriate antibiotics. After the infection was cleared or if no infection was present, treatment consisted of: (1) repositioning the distal catheter into the peritoneum, (2) repositioning the distal catheter into the pleural space, the atrium, or the gallbladder, (3) exploratory laparotomy with lysis of adhesions and repositioning the peritoneal catheter, (4) APC aspiration only, or (5) shunt removal or disconnection. Because of the complexity of APC management, we analyzed the outcomes of our cases and outlined an algorithm to simplify this process.     

膜周部室间隔缺损经导管介入封堵后早期并发症危险因素的分析

目的：探讨膜周部室间隔缺损（VSD）经介入治疗后早期并发症的危险因素。 方法：回顾性纳入2015年10月1日至2017年10月1日在重庆医科大学附属儿童医院行膜周部VSD介入封堵术的患儿,从医院电子病历系统中截取临床资料,分析术后总并发症、新发心律失常、残余分流、新发中度及以上反流的危险因素。 结果：①186例患儿进入本文分析,男97例,年龄18~148（45.4±25.4）个月,体重8.5~48（15.7±6.1) kg;超声缺损（5.6±1.9）mm,压差（68.6±13.7）mmHg,距主动脉瓣距离＜3 mm 8例（4.3%）,术前有心律失常18例（9.7%）,合并膜部瘤70例（37.6%）;封堵器大小（6.3±1.2）mm,封堵器形状对称178例（95.7%）、偏心8例;麻醉方式为全麻147例（79%）、局麻39例,手术时间（38.8±15.0）min。②术后住院期间共发生并发症60例（32.3%）,新发心律失常30例（16.1%）;残余分流30例（16.1%）,其中1例为大量分流;新发中度及以上瓣膜反流9例（4.8%）,均为三尖瓣反流。③多因素Logistic回归分析显示,总并发症：超声下大缺损（OR=1.264,95％CI: 1.040～1.536,P=0.019）和偏心型封堵器（OR=6.732,95％CI: 1.018～44.509,P=0.048）为危险因素;残余分流：超声下大缺损（OR=1.577,95％CI: 1.154～2.155,P=0.004）和右心室收缩压升高（OR=1.080,95％CI: 1.001～1.165,P=0.047）为危险因素,左心室平均压升高为保护因素（OR=0.913,95％CI: 0.864～0.966,P=0.001）;新发中度及以上瓣膜反流：右心室收缩压升高（OR=1.068,95％CI: 1.006～1.133,P=0.030）和更大的封堵器（OR=1.585,95％CI: 1.003～2.506,P=0.048）为危险因素。 结论：超声下VSD大小、封堵器的大小与形状、右心室收缩压、左心室平均压与膜周部VSD介入治疗术后早期并发症发生有关,同时提示血流动力学稳定性、右心功能在术后并发症发生中的重要作用。     

Predictors of ventriculoperitoneal shunt pathology.

BACKGROUND: Diagnosis of ventriculoperitoneal (VP) shunt pathology remains a dilemma in patients with nonspecific constitutional signs and symptoms. Eosinophilia has been described in association with shunt infection and malfunction. Our purpose was to further define the relationship of eosinophilia and shunt pathology and to determine other predictors of VP shunt infection and malfunction. METHODS: Records of all patients admitted with a suspected VP shunt infection or malfunction were reviewed. The following data were abstracted: age; reason for and age at initial shunt placement; number of revisions; date of last revision; history of fever or vomiting; ventricular fluid cell count; differential and culture; complete blood count and differential; need for shunt revision or replacement; and use of antibiotics. After exclusion of patients admitted for initial shunt placement, the remainder were divided into three groups: those with shunt infection; those with shunt malfunction; and those without documented infection or malfunction. RESULTS: Of 12 patients with shunt infection and 69 with shunt malfunction, 2 and 11, respectively, had eosinophilia defined as > or =5%. The presence of eosinophilia had a 96% positive predictive value for shunt pathology and raised the pretest probability of pathology from 84% to a post test probability of 96%. The combination of fever history and ventricular fluid neutrophils >10% had a 99% specificity for shunt infection, had a 93 and 95% positive and negative predictive value, respectively, and raised the pretest probability of infection from 12% to a posttest probability of 92%. CONCLUSIONS: In patients suspected of having a VP shunt malfunction, the presence of > or =5% eosinophils in the ventricular fluid indicates shunt pathology. The combination of fever and ventricular fluid neutrophils > 10% is predictive of shunt infection.     

The programmable adult Codman Hakim valve is useful even in very small children with hydrocephalus. A 7-year retrospective study with special focus on cost/benefit analysis.

INTRODUCTION: Ventriculo-peritoneal shunting is the most commonly used method for the treatment of paediatric hydrocephalus. The programmable valve with the ability to adjust the opening pressure non-invasively has made it easier to find exactly the right opening pressure for each child and reduce the risk of over- or under-drainage. The aim of this investigation was to study our clinical experience with the adult Codman Hakim programmable valve in children, with reference to complications and economic impact. METHODS: A seven-year retrospective study of 122 hydrocephalic children (aged from children born prematurely to 15 years old) shunted with the adult Codman Hakim programmable valve was performed. RESULTS: The programmable valve was the first shunt in 76 children and in 14 after prior ventricular drainage. The remaining 46 had different non-programmable systems as their first shunt. The most common reason for changing to a programmable valve was over-drainage. With the programmable valve, catheter-related complications, e.g. proximal (36%) or distal obstructions (30%), were the main reasons for surgical revision. Non-invasive pressure adjustment was performed in 73% of the children. Among the children with the programmable valve as their first shunt, 57 (75%) were adjusted, 12 (21%) had severe symptoms of over-drainage and would have required urgent surgical change of the valve if it had not been adjustable. A resetting of the opening pressure after MRI was found in 38% and accidental resetting occurred in 4%. Programmable valves are about twice as expensive as non-programmable valves. We estimated the increased cost of the valve and compared it with the savings from a reduction in the number of re-operations. The total cost for the programmable valve (as the primary shunt) in our study was less than that for expected re-operations due to over- or under-drainage when using non-programmable valves. CONCLUSION: The programmable valve was easy to handle; only one size was required and the adjustment made it possible to achieve an optimal intraventricular pressure with a lower total cost, reduced hospital stay as well as an increased quality of life for the children.     

Marvelous medicine: the untold story of the Wade-Dahl-Till valve

On December 5, 1960, 4-month-old Theo Dahl, the only son of best-selling author Roald Dahl (1916-1990), had his skull shattered in a horrific traffic accident. What began as a personal tragedy for the Dahl family would soon evolve into a dogged crusade by Dahl to expand upon preexisting valve technology with the goal of developing a shunt that would not become obstructed. Based upon exclusive access to private archives of the Dahl estate, as well as interviews with those involved, this article tells the intricate tale of one famous father's drive to significantly alter the natural history of pediatric hydrocephalus. Dahl's collaboration with British toymaker Stanley Wade and pioneering pediatric neurosurgeons Joseph Ransohoff, Kenneth Shulman, and Kenneth Till to create the Wade-Dahl-Till (WDT) valve is examined in detail. The ensuing rift between the American and British contingents, the valve's multiple design revisions, and the goal of creating an affordable shunt for children in developing countries are among the issues addressed. The development of the WDT valve marked a significant turning point in the surgical management of pediatric hydrocephalus in general and in shunt valve technology in particular.     

Pitfalls in the diagnosis of ventricular shunt dysfunction: radiology reports and ventricular size

INTRODUCTION: The diagnosis of shunt malfunction can be difficult even for the experienced clinician and may lead to disastrous circumstances when misinterpreted. Less experienced physicians may rely more on radiographic reports as a primary diagnostic modality. In this study, we evaluated the reliability of using these reports without accurate clinical assessment. METHODS: All shunt revisions seen at Children's Hospital (Birmingham, AL) between January 1996 and August 1996 were reviewed, excluding patients with brain tumors, supratentorial extraaxial fluid collections, and infections. Sixty-eight patients underwent 100 operations for shunt malfunction. All patients had evidence of shunt blockage, disconnection, catheter malposition, or valve pressure incompatibility. The prospective radiographic interpretation of preoperative computed tomography and magnetic resonance imaging scans was reviewed in each case. RESULTS: Twenty-four percent of the reports made no mention of shunt malfunction. In this group, the ventricular system was described as "unchanged," "stable," "normal," "unremarkable," "small," "smaller," "slit," "negative," and "no hydrocephalus," with no other comment to support a diagnosis of shunt malfunction. An additional 9% of reports contained the same terms, while also hinting at some other clinical or radiographic data that suggest the possibility of shunt failure (e.g., a shunt disconnection seen on plain radiographs), despite the scan findings. In all patients in this group, symptoms improved after surgery. CONCLUSION: We conclude that as many as one third of patients presenting with shunt malfunction will not have the diagnosis of shunt malfunction supported by a prospective radiologic interpretation of brain imaging. Although the neurosurgical community can assess the clinical situation to determine the need for surgery, other clinicians can be easily reassured by a radiographic report that does not mention or diagnose shunt malfunction. Today, more than ever, nonneurosurgeons are being called on to evaluate complex clinical situations and may rely on radiographic reports.     

Long-term follow-up data from the Shunt Design Trial

Background: A previously reported multicenter randomized trial assessed whether 2 new shunt valve designs would reduce shunt failure rates compared to differential pressure valves. The study did not show a significant difference in the time to first shunt failure. Patients entered the trial between October 1, 1993, and October 31, 1995. The primary results were based on the patients' status as of October 31, 1996 (a minimum follow-up of 1 year). This report describes the late complications based on the patients' most recent follow-up. Methods: Three hundred and forty-four hydrocephalic children at 12 North American and European centers were randomized to 1 of 3 valves: a standard differential pressure valve; a Delta valve (PS Medical-Medtronic) or a Sigma valve (NMT Cordis). Patients were followed until their first shunt failure. Shunt failure was defined as shunt surgery for obstruction, overdrainage, loculation or infection. If the shunt did not fail, follow-up was continued until August 31, 1999. Results: One hundred and seventy-seven patients had shunt failure. Shunt obstruction occurred in 131, overdrainage in 13, loculated ventricles in 2 and infection in 29. The overall shunt survival was 62% at 1 year, 52% at 2 years, 46% at 3 years, 41% at 4 years. The survival curves for the 3 valves were similar to those from the original trial and did not show a survival advantage for any particular valve. Conclusions: Prolonged follow-up to date does not alter the primary conclusions of the trial: there does not appear to be one valve that is clearly the best for the initial treatment of pediatric hydrocephalus.     

Shunt revision in hydrocephalus

Objective : A retrospective analysis of 50 hydrocephalic children having a minimum follow-up of 6 months was carried out to see their etiology, clinical features, complications, incidence of shunt revisions, outcome and the variation from their Western counterparts.Methods : Clinical features, image findings and treatment of all the cases were recorded from their discharge summaries. Record of shunt revision complications and outcome was maintained by the principal author. The data of all the cases were analyzed.Results : The age of children varied from 1 month to 12 yr (mean 2.2 yr). The most common etiology of hydrocephalus was aqueductal stenosis in 18 (36%) children. Post infective hydrocephalus, either of post-tubercular meningitis (TBM) or following bacterial meningitis, remained the cause in 15 children (30%). Congenital TORCH infection was responsible for 3 cases of hydrocephalus making infective etiology as the cause in 18 (36%) cases. Intra 4^th ventricular neurocysticercus cyst caused blockade of CSF pathway in 2 children. 15 out of 50 children required shunt revision, either due to infection (8,16%) or shunt obstruction (7, 14%). Multiple shunt revisions were required in 2 children only. These revisions were required due to infection, obstruction or malfunction of the shunt.Conclusions : Infective etiology is responsible for hydrocephalus in significant number of children (36%). The possibility of TORCH infection, as a cause of hydrocephalus should be considered even amongst the children of screened mothers during antenatal check-up. Pure intra 4^th ventricular neurocysticercus cysts (without intraparenchymal cyst), though rare, can manifest with outlet obstruction. Incidence of shunt revision using Chhabra’s medium pressure shunt is very high in children at an average follow up of 1.6 yr. Post infective hydrocephalus is a major cause of delayed milestones, contributing to mental retardation.     

Physical examination of patients with cerebrospinal fluid shunts: is there useful information in pumping the shunt?

To assess the value of the information derived from pumping the shunt valve in hydrocephalic patients with cerebrospinal fluid shunts, the findings on examination of 200 consecutive patients were recorded prospectively. The status of each shunt was determined on the basis of all available clinical data, and the results of the shunt pumping test were compared to the final status of each shunt for various subsets of the study group. In the most clinically pertinent subsets, the sensitivity of the shunt pumping test in the detection of shunt obstruction was 18% to 20%, and the predictive value of a negative shunt pumping test, indicating shunt patency, was only 65% to 81%. For the hydrocephalic patient with symptoms of shunt malfunction, definitive imaging studies must not be deferred because of reassuring findings on examination of the shunt valve.     

Telemetric assessment of intracranial pressure changes consequent to manipulations of the Codman-Medos programmable shunt valve

INTRODUCTION: Noninvasive manipulation of programmable shunt valves may allow customization of intracranial pressure (ICP) dynamics in individual shunted patients. Manipulations of the recently FDA-approved Codman-Medos variable pressure valve (VPV) are monitored by radiographic changes in the valve mechanism, necessitating a skull radiograph with each pressure change. We wished to assess the in vivo impact of VPV manipulations on ICP changes using a noninvasive telemonitor as an alternative to radiographic confirmation and as a method for validating the ICP changes. METHODS: TeleSensor devices (Radionics) were implanted in-line with 12 VPV shunt systems. ICP was assessed telemetrically in the supine position whenever the valve pressure was adjusted (both before and 2-5 min after the manipulation). RESULTS: Valve manipulation was confirmed by radiograph for the initial manipulations only and matched the telemetric pressure changes observed in all cases. Confirmed manipulations of the valve were generally followed by a near equivalent relative change in ICP (相似文献   

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.     

左胸肋间入路微创封堵手术治疗干下型室间隔缺损

目的总结左胸肋间入路微创封堵手术治疗干下型室间隔缺损(VSD)的初步经验。方法2014年2月至2 015年9月我们对19例干下型VSD患儿施行外科微创封堵手术,其中男性10例,女性9例;年龄0.5~17岁,平均(3.2±4.3)岁;体重5.5~50.0 kg,平均(14.3±10.9)kg;缺损直径3.5~9.0 mm,平均(5.4±1.8)mm;合并主动脉瓣右冠瓣轻度脱垂6例,主动脉瓣局限~轻微反流3例,肺动脉瓣轻中度狭窄1例,轻度狭窄1例。均采用左胸肋间入路,在经食管超声心动图(TEE)监视下建立VSD输送轨道并置入封堵器,观察有无残余分流及主动脉瓣反流;于出院前、手术后定期复查经胸超声心动图和心电图。结果 18例封堵手术获成功,因新发主动脉瓣中度反流及残余分流而中转开胸手术1例。术中新发主动脉瓣轻微反流2例,术前合并主动脉瓣反流患者中有2例反流加重。手术时间35~85 min,平均手术时间(55.7±15.9)min。术中出血量3~200 mL,平均(22.7±43.3)mL。围手术期输血1例。术后住院时间3~13 d,平均(4.2±2.3)d。术后出现残余分流、上呼吸道感染、伤口感染各1例。随访6~25个月,平均(14.7±7.0)个月,随访期间1例新发主动脉瓣反流,1例术中新发主动脉瓣反流消失,2例术后仍有主动脉瓣反流患者反流无明显变化,1例残余分流愈合,无传导阻滞发生。结论左胸肋间封堵手术治疗干下型VSD手术安全,操作简单,创伤小,恢复快,近期效果满意,远期效果需进一步随访;对合并主动脉瓣脱垂尤其主动脉瓣反流的干下型VSD需慎重施行外科徽创封堵手术。     

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.     

The shunt design trial: variation in surgical experience did not influence shunt survival.

INTRODUCTION: An international multicenter randomized trial comparing standard pressure differential valves, Orbis Sigma valves and PS Medical Delta valves for children with newly diagnosed hydrocephalus failed to show a difference in the time to first shunt failure. Surgeons' prior experience with the three valves varied. This analysis was performed to assess whether lack of surgical experience with any of the valves could explain the overall negative result. METHODS: (1) Shunt survival was compared at high- and low-volume centers. (2) The 1-year shunt survival rates (+/-95% confidence interval) for patients entered in the first quarter and the last quarter of the 25-month accrual period were compared (for all patients, and for each shunt). RESULTS: Survival curves for high- and low-volume centers were similar. Ninety of the 344 randomized patients were accrued in the first quarter and 93 in the last quarter. The 1-year shunt survival for all patients entered in the first quarter was 72% (+/-11%) compared to 64% (+/-10%) for patients entered in the last quarter. The shunt-specific results were 66% (+/-20%) compared to 54% (+/-20%) for Delta valve patients, 75% (+/-20%) compared to 70% (+/-17%) for standard valve patients and 76% (+/-18%) compared to 66% (+/-16%) for Orbis Sigma patients. DISCUSSION: Shunt survival did not improve as surgeons accumulated experience over the course of the study. Although participating surgeons had varying levels of experience with the different shunts at the start of the trial, this does not appear to explain the overall negative trial result.