Diagnostic Accuracy of Non-Invasive Thermal Evaluation of Ventriculoperitoneal Shunt Flow in Shunt Malfunction: A Prospective, Multi-Site, Operator-Blinded Study

Abstract BACKGROUND Thermal flow evaluation (TFE) is a non-invasive method to assess ventriculoperitoneal shunt function. Flow detected by TFE is a negative predictor of the need for revision surgery. Further optimization of testing protocols, evaluation in multiple centers, and integration with clinical and imaging impressions prompted the current study. OBJECTIVE To compare the diagnostic accuracy of 2 TFE protocols, with micropumper (TFE+MP) or without (TFE-only), to neuro-imaging in patients emergently presenting with symptoms concerning for shunt malfunction. METHODS We performed a prospective multicenter operator-blinded trial of a consecutive series of patients who underwent evaluation for shunt malfunction. TFE was performed, and preimaging clinician impressions and imaging results were recorded. The primary outcome was shunt obstruction requiring neurosurgical revision within 7 d. Non-inferiority of the sensitivity of TFE vs neuro-imaging for detecting shunt obstruction was tested using a prospectively determined a priori margin of −2.5%. RESULTS We enrolled 406 patients at 10 centers. Of these, 68/348 (20%) evaluated with TFE+MP and 30/215 (14%) with TFE-only had shunt obstruction. The sensitivity for detecting obstruction was 100% (95% CI: 88%-100%) for TFE-only, 90% (95% CI: 80%-96%) for TFE+MP, 76% (95% CI: 65%-86%) for imaging in TFE+MP cohort, and 77% (95% CI: 58%-90%) for imaging in the TFE-only cohort. Difference in sensitivities between TFE methods and imaging did not exceed the non-inferiority margin. CONCLUSION TFE is non-inferior to imaging in ruling out shunt malfunction and may help avoid imaging and other steps. For this purpose, TFE only is favored over TFE+MP.

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Ventriculoperitoneal Shunt Malfunction during Pregnancy

Neurosurgery ◽

10.1227/00006123-199012000-00017 ◽

1990 ◽

Vol 27 (6) ◽

pp. 969-971 ◽

Cited By ~ 17

Author(s):

Michael D. Cusimano ◽

Filomena M. Meffe ◽

Fred Gentili ◽

Mathew Sermer

Keyword(s):

Cerebrospinal Fluid ◽

Ventriculoperitoneal Shunt ◽

Reproductive Age ◽

Shunt Malfunction ◽

Cerebrospinal Fluid Shunts ◽

Third Trimester ◽

The Third ◽

Shunt Obstruction

Abstract Many women with cerebrospinal fluid shunts are now reaching reproductive age. Shunt malfunction may occur during pregnancy, and management requires a well-planned, combined neurosurgical and obstetrical approach. We present a case of ventriculoperitoneal shunt obstruction manifesting during the third trimester managed successfully in a conservative fashion. The literature on ventriculoperitoneal shunt malfunction during pregnancy is reviewed.

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Characteristics of Ventricular Shunt Malfunctions among Patients with Neurocysticercosis

Neurosurgery ◽

10.1097/00006123-200204000-00014 ◽

2002 ◽

Vol 50 (4) ◽

pp. 757-762 ◽

Cited By ~ 52

Author(s):

Rosemarie Kelley ◽

Duc H. Duong ◽

George E. Locke

Keyword(s):

Disease Activity ◽

Ventriculoperitoneal Shunt ◽

Chart Review ◽

Retrospective Chart Review ◽

Distal Segment ◽

Shunt Malfunction ◽

Proximal Segment ◽

Shunt Failure ◽

Shunt Placement ◽

Shunt Obstruction

Abstract OBJECTIVE: Ventricular shunts used to relieve hydrocephalus among patients with neurocysticercosis have been plagued by high shunt malfunction rates. We examined the characteristics of shunt malfunctions among patients with neurocysticercosis. METHODS: This is a retrospective chart review of data for 122 patients who were admitted with a diagnosis of cysticercosis during a 5.5-year period. Cases of hydrocephalus requiring shunt placement were reviewed with respect to the segment of shunt obstruction, disease activity at the time of shunt placement, and the effects of antihelminthic treatment on shunt failures and longevity. RESULTS: Twenty-one patients required 49 operations for relief of hydrocephalus, including 22 new shunt placements, 23 revisions, and 4 cyst extirpations. Of these shunt failures, 78% occurred within the first 12 months and 96% within 3 years. Of the failures that occurred in the distal segment, 75% occurred within 6 months. By comparison, 33% of proximal segment obstructions and 50% of the total number of valve obstructions occurred within the first 6 months. Of the shunts placed during the vesicular stage of infection, 63% required revisions, compared with 29% of those placed during the colloidal through calcified stages. Nineteen shunts were placed during the vesicular stage, and nine patients received a full course of antihelminthic treatment after shunt placement. In less than 6 months, 33% of the cases involving shunt placement followed by antihelminthic treatment exhibited shunt failure, compared with 90% of the cases without antihelminthic treatment (P < 0.05, χ2 test). CONCLUSION: Among patients with vesicular stage cysticercosis, placement of a ventriculoperitoneal shunt followed by a course of antihelminthic medication seems to promote shunt longevity.

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Rethinking the indications for the ventriculoperitoneal shunt tap

Journal of Neurosurgery Pediatrics ◽

10.3171/ped/2008/1/6/435 ◽

2008 ◽

Vol 1 (6) ◽

pp. 435-438 ◽

Cited By ~ 10

Author(s):

Jonathan P. Miller ◽

Steven C. Fulop ◽

Shervin R. Dashti ◽

Shenandoah Robinson ◽

Alan R. Cohen

Keyword(s):

Ventriculoperitoneal Shunt ◽

Shunt Infection ◽

Shunt Malfunction ◽

Shunt Revision ◽

Status Change ◽

Suspected Infection ◽

Evaluation Protocol ◽

Distal Obstruction ◽

Abdominal Radiographs ◽

Shunt Obstruction

Object Tapping of a suspected malfunctioning ventriculoperitoneal shunt is usually easy, sometimes informative, but also potentially misleading. The purpose of this study was to determine the effectiveness of a shunt evaluation protocol that does not involve direct shunt tapping except in rare and specific cases. Methods The authors adopted a protocol for shunt evaluation that involves shunt tapping only in selected cases of suspected infection or in patients with noncommunicating hydrocephalus and equivocal computed tomography (CT) findings of shunt infection. They then reviewed the clinical characteristics and surgical findings in 373 consecutive assessments of 155 pediatric patients who were evaluated for shunt malfunction and/or infection by using this protocol between January 2003 and December 2005. Results Mental status change and headache were the symptoms most concordant with shunt malfunction, but no symptom had a predictive value much better than 50%. Follow-up CT scans demonstrated enlarged ventricles in 72 of 126 cases of shunt revision. Among those with obstruction but without remarkable CT changes, 8 patients had evidence of distal obstruction on x-ray “shunt series” consisting of skull, chest, and abdominal radiographs, and 5 had obvious symptoms that rendered further testing unnecessary; 38 cases of obstruction were diagnosed based on elevated opening pressure on lumbar puncture (mean 34.7 cm H2O). A shunt tap was required in only 8 cases (2%). Conclusions The authors have shown that it is possible to evaluate the majority of ventricular shunt malfunctions without tapping the device. Because it is possible to diagnose shunt obstruction correctly by other means, the shunt tap may not be obligatory as a routine test of the device's patency.

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Diagnostic accuracy of transvaginal sonography (TVS) for non-invasive diagnosis of rectosigmoidal endometriosis – a systematic review and meta-analysis

Geburtshilfe und Frauenheilkunde ◽

10.1055/s-0031-1278538 ◽

2011 ◽

Vol 71 (05) ◽

Author(s):

G Hudelist ◽

J English ◽

A Thomas ◽

A Tinelli ◽

C Singer ◽

...

Keyword(s):

Systematic Review ◽

Diagnostic Accuracy ◽

Meta Analysis ◽

Transvaginal Sonography ◽

Non Invasive

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Diagnostic efficacy and suitability of trans-thoracic ultrasonography for pleural fluid detection – The future non-invasive gold-standard?

Journal of Fatima Jinnah Medical University ◽

10.37018/jfjmu.558 ◽

2020 ◽

Vol 13 (4) ◽

pp. 184-190

Author(s):

Muhammad Irfan ◽

Abdul Rasheed Qureshi ◽

Zeeshan Ashraf ◽

Muhammad Amjad Ramzan ◽

Tehmina Naeem ◽

...

Keyword(s):

Pleural Effusion ◽

Diagnostic Accuracy ◽

Pleural Fluid ◽

Gold Standard ◽

Pleural Effusions ◽

Diagnostic Efficacy ◽

Chest Sonography ◽

X Ray ◽

Non Invasive ◽

Fluid Detection

ABSTRACT Background: Conventionally Pleural effusions are suspected by history of pleuritis, evaluated by physical signs and multiple view radiography. Trans-thoracic pleural aspiration is done and aspirated pleural fluid is considered the gold-standard for pleural effusion. Chest sonography has the advantage of having high diagnostic efficacy over radiography for the detection of pleural effusion. Furthermore, ultrasonography is free from radiation hazards, inexpensive, readily available and feasible for use in ICU, pregnant and pediatric patients. This study aims to explore the diagnostic accuracy of trans-thoracic ultrasonography for pleural fluid detection, which is free of such disadvantages. The objective is to determine the diagnostic efficacy of trans-thoracic ultrasound for detecting pleural effusion and also to assess its suitability for being a non-invasive gold-standard. Subject and Methods: This retrospective study of 4597 cases was conducted at pulmonology OPD-Gulab Devi Teaching Hospital, Lahore from November 2016 to July 2018. Adult patients with clinical features suggesting pleural effusions were included while those where no suspicion of pleural effusion, patients < 14 years and pregnant ladies were excluded. Patients were subjected to chest x-ray PA and Lateral views and chest ultrasonography was done by a senior qualified radiologist in OPD. Ultrasound-guided pleural aspiration was done in OPD & fluid was sent for analysis. At least 10ml aspirated fluid was considered as diagnostic for pleural effusion. Patient files containing history, physical examination, x-ray reports, ultrasound reports, pleural aspiration notes and informed consent were retrieved, reviewed and findings were recorded in the preformed proforma. Results were tabulated and conclusion was drawn by statistical analysis. Results: Out of 4597 cases, 4498 pleural effusion were manifested on CXR and only 2547(56.62%) pleural effusions were proved by ultrasound while 2050 (45.57%) cases were reported as no Pleural effusion. Chest sonography demonstrated sensitivity, specificity, PPV, NPV and diagnostic accuracy 100 % each. Conclusions: Trans-thoracic ultrasonography revealed an excellent efficacy that is why it can be considered as non-invasive gold standard for the detection of pleural effusion.

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CT diagnosis of ilioinguinal lymph node metastases in melanoma using radiological characteristics beyond size and asymmetry

BJS Open ◽

10.1093/bjsopen/zraa005 ◽

2021 ◽

Vol 5 (1) ◽

Author(s):

M J Wilkinson ◽

H Snow ◽

K Downey ◽

K Thomas ◽

A Riddell ◽

...

Keyword(s):

Lymph Node ◽

Diagnostic Accuracy ◽

Multivariable Analysis ◽

Ct Scans ◽

Non Invasive ◽

Poor Predictor ◽

Contrast Enhanced Ct ◽

Contrast Enhanced ◽

Enhanced Ct ◽

Node Metastases

Abstract Background Diagnosis of lymph node (LN) metastasis in melanoma with non-invasive methods is challenging. The aim of this study was to evaluate the diagnostic accuracy of six LN characteristics on CT in detecting melanoma-positive ilioinguinal LN metastases, and to determine whether inguinal LN characteristics can predict pelvic LN involvement. Methods This was a single-centre retrospective study of patients with melanoma LN metastases at a tertiary cancer centre between 2008 and 2016. Patients who had preoperative contrast-enhanced CT assessment and ilioinguinal LN dissection were included. CT scans containing significant artefacts obscuring the pelvis were excluded. CT scans were reanalysed for six LN characteristics (extracapsular spread (ECS), minimum axis (MA), absence of fatty hilum (FH), asymmetrical cortical nodule (CAN), abnormal contrast enhancement (ACE) and rounded morphology (RM)) and compared with postoperative histopathological findings. Results A total of 90 patients were included. Median age was 58 (range 23–85) years. Eighty-eight patients (98 per cent) had pathology-positive inguinal disease and, of these, 45 (51 per cent) had concurrent pelvic disease. The most common CT characteristics found in pathology-positive inguinal LNs were MA greater than 10 mm (97 per cent), ACE (80 per cent), ECS (38 per cent) and absence of RM (38 per cent). In multivariable analysis, inguinal LN characteristics on CT indicative of pelvic disease were RM (odds ratio (OR) 3.3, 95 per cent c.i. 1.2 to 8.7) and ECS (OR 4.2, 1.6 to 11.3). Cloquet’s node is known to be a poor predictor of pelvic spread. Pelvic LN disease was present in 50 per cent patients, but only 7 per cent had a pathology-positive Cloquet’s node. Conclusion Additional CT radiological characteristics, especially ECS and RM, may improve diagnostic accuracy and aid clinical decisions regarding the need for inguinal or ilioinguinal dissection.

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Diagnostic accuracy of Instantaneous Wave-Free Ratio (iFR) for the assessment of myocardial ischaemia: a comparison with non-invasive stress imaging

European Heart Journal ◽

10.1093/ehjci/ehaa946.1369 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

L Stazzoni ◽

L Tessandori ◽

P Spontoni ◽

M Angelillis ◽

C Giannini ◽

...

Keyword(s):

Diagnostic Accuracy ◽

Myocardial Ischaemia ◽

Gold Standard ◽

Coronary Revascularization ◽

Stress Test ◽

Invasive Coronary Angiography ◽

Coronary Syndrome ◽

Non Invasive ◽

Coronary Stenoses ◽

Epicardial Stenosis

Abstract Background Instantaneous Wave-Free Ratio (iFR) allows for the assessment of the haemodynamic effects of epicardial coronary stenoses without the need for hyperaemia; iFR is currently recommended as a means to evaluate myocardial ischaemia. Purpose To assess the diagnostic accuracy of iFR with respect to the identification of coronary epicardial stenoses causing ischemia. Therefore, we combined anatomical (% stenosis at invasive coronary angiography, ICA) and functional (non-invasive imaging stress test, NIST) information to obtain a “gold standard” for the identification of stenoses causing ischaemia. Methods We enrolled 71 patients (52 male, 19 female; age mean 68.4±8.1 years) with chronic coronary syndrome or low-risk acute coronary syndrome without ST segment elevation who had at least a NIST and who had at least one vessel with a 50%-85% stenosis at ICA. iFR was measured in all coronary arteries with stenosis >50% and categorised according to the 0.89 threshold for ischaemia. Results iFR was assessed in 122 vessels. In a per-vessel analysis, in 56.7% ischaemia was present both at iFR and NIST, in 21.3% ischaemia was absent in both, while in 23.0% ischaemia was found at NIST but not confirmed by iFR. The overall accuracy of iFR with respect to NIST was 90.1%. However, when considering as the “gold standard” for coronary disease causing ischaemia the contemporary presence of an epicardial stenosis >70% at ICA and a positive NIST, the diagnostic accuracy of iFR greatly improved. The sensibility, specificity, PPV, NPV and accuracy were 96.5%, 75.0%, 73.3%, 96.7% and 84.4%, respectively. In case of discordance between NIST and iFR, revascularization was based on iFR. At a mean follow-up of 23±18 months, the composite endpoint of MACE (major adverse cardiac events, defined as the composite of all-cause death, nonfatal MI and unplanned coronary revascularization) occurred in 16.4%, while death/MI occurred in 11.9%. Stratification according to the per-patient concordance between iFR and NIST showed no significant differences in rates of MACE (p=0.50) and death/MI (p=0.20). Stratification based on iFR showed a higher death/MI rate in iFR-positive patients (11.9% vs. 0%, p=0.047) and a trend to higher MACE rate (11.9% vs. 4.47% p=0.14), Conclusions The diagnostic accuracy of iFR is low when compared with NIST as the reference for myocardial ischaemia, but it is very high when compared with the combined presence of epicardial stenosis and positive NIST. Therefore, iFR can accurately guide the decision to treat or defer revascularization of intermediate coronary stenoses, being most useful in patients with multivessel CAD and when non-invasive functional data are lacking or discordant with anatomy. Funding Acknowledgement Type of funding source: None

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