scholarly journals Modular Redundancy for Cerebrospinal Fluid Shunts: Reducing Incidence of Failure due to Catheter Obstruction

2019 ◽  
Author(s):  
Tom Viker ◽  
Jim Stice
Keyword(s):  
Cerebrospinal Fluid ◽  
Low Cost ◽  
Shunt Revision ◽  
Csf Shunt ◽  
Cerebrospinal Fluid Shunts ◽  
Distal Catheter ◽  
Catheter Occlusion ◽  
Single Lumen ◽  
Catheter Obstruction ◽  
Lumen Catheter

Cerebrospinal fluid shunts for the treatment of hydrocephalus fail at a rate of 40% within the first year. The importance of this problem is supported by one institution’s analysis of neurosurgical 30-day readmissions with CSF shunt failure only second to brain tumor readmissions. Hospital shunt related costs have been estimated at $1.4 to $2 billion annually. The majority of these costs are attributable to shunt failures based on the number of revisions out of the total numbers of annual shunt procedures. The technical innovation of this project is a low cost, low risk and easy to implement CSF shunt design change compatible with current protocols. The proposed product is an innovative distal catheter to minimize the need for revision surgery due to obstruction (also referred to as occlusion). This is accomplished with a dual lumen catheter (current distal catheters are single lumen) consisting of a primary lumen and a secondary lumen providing redundant functionality in the event ofprimary lumen occlusion thereby eliminating the need for surgical shunt revision. 40% of shunts fail within the year after implant and distal catheter obstruction accounts for up to 24% of failures. Though less prevalent than proximal catheter occlusion, incidence of distal catheter occlusion is significant and improved reliability would reduce costs and improve patient outcomes by lowering the number of revisions.

scholarly journals Survival and failure trends of cerebrospinal fluid shunts with distal slit valves: comparative study and literature review

2020 ◽  
Vol 25 (3) ◽  
pp. 209-216
Author(s):  
Jeremy S. Wetzel ◽  
Alex D. Waldman ◽  
Pavlos Texakalidis ◽  
Bryan Buster ◽  
Sheila R. Eshraghi ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Failure Rate ◽  
Csf Shunt ◽  
Time To Failure ◽  
Survival Curves ◽  
Mean Time To Failure ◽  
Distal Catheter ◽  
Catheter Obstruction ◽  
Shunt Survival ◽  
Mean Time

OBJECTIVEThe malfunction rates of and trends in various cerebrospinal fluid (CSF) shunt designs have been widely studied, but one area that has received little attention is the comparison of the peritoneal distal slit valve (DSV) shunt to other conventional valve (CV) type shunts. The literature that does exist comes from older case series that provide only indirect comparisons, and the conclusions are mixed. Here, the authors provide a direct comparison of the overall survival and failure trends of DSV shunts to those of other valve type shunts.METHODSThree hundred seventy-two new CSF shunts were placed in pediatric patients at the authors’ institution between January 2011 and December 2015. Only ventriculoperitoneal (VP) shunts were eligible for study inclusion. Ventriculoatrial, lumboperitoneal, cystoperitoneal, subdural-peritoneal, and spinal shunts were all excluded. Rates and patterns of shunt malfunction were compared, and survival curves were generated. Patterns of failure were categorized as proximal failure, distal failure, simultaneous proximal and distal (proximal+distal) failure, removal for infection, externalization for abdominal pseudocyst, and addition of a ventricular catheter for loculated hydrocephalus.RESULTSA total of 232 VP shunts were included in the final analysis, 115 DSV shunts and 117 CV shunts. There was no difference in the overall failure rate or time to failure between the two groups, and the follow-up period was statistically similar between the groups. The DSV group had a failure rate of 54% and a mean time to failure of 17.8 months. The CV group had a failure rate of 50% (p = 0.50) and a mean time to failure of 18.5 months (p = 0.56). The overall shunt survival curves for these two groups were similar; however, the location of failure was significantly different between the two groups. Shunts with DSVs had proportionately more distal failures than the CV group (34% vs 14%, respectively, p = 0.009). DSV shunts were also found to have proximal+distal catheter occlusions more frequently than CV shunts (23% vs 5%, respectively, p = 0.005). CV shunts were found to have significantly more proximal failures than the DSV shunts (53% vs 27%, p = 0.028). However, the only failure type that carried a statistically significant adjusted hazard ratio in a multivariate analysis was proximal+distal catheter obstruction (CV vs DSV shunt: HR 0.21, 95% CI 0.05–0.81).CONCLUSIONSThere appears to be a difference in the location of catheter obstruction leading to the malfunction of shunts with DSVs compared to shunts with CVs; however, overall shunt survival is similar between the two. These failure types are also affected by other factors such etiology of hydrocephalus and endoscope use. The implications of these findings are unclear, and this topic warrants further investigation.

scholarly journals Cerebrospinal fluid biomarkers of neuroinflammation in children with hydrocephalus and shunt malfunction

2021 ◽  
Vol 18 (1) ◽  
Author(s):  
Carolyn A. Harris ◽  
Diego M. Morales ◽  
Rooshan Arshad ◽  
James P. McAllister ◽  
David D. Limbrick
Keyword(s):  
Cerebrospinal Fluid ◽  
Inflammatory Cytokines ◽  
Protein Concentration ◽  
Shunt Revision ◽  
Csf Shunt ◽  
Shunt Failure ◽  
Revision Operation ◽  
Protein Levels ◽  
Anti Inflammatory ◽  
Pro Inflammatory Cytokines

Abstract Background Approximately 30% of cerebrospinal fluid (CSF) shunt systems for hydrocephalus fail within the first year and 98% of all patients will have shunt failure in their lifetime. Obstruction remains the most common reason for shunt failure. Previous evidence suggests elevated pro-inflammatory cytokines in CSF are associated with worsening clinical outcomes in neuroinflammatory diseases. The aim of this study was to determine whether cytokines and matrix metalloproteinases (MMPs) contribute towards shunt failure in hydrocephalus. Methods Using multiplex ELISA, this study examined shunt failure through the CSF protein concentration profiles of select pro-inflammatory and anti-inflammatory cytokines, as well as select MMPs. Interdependencies such as the past number of previous revisions, length of time implanted, patient age, and obstruction or non-obstruction revision were examined. The pro-inflammatory cytokines were IL-1β, IL-2, IL-5, IL-6, IL-8, IL-12, IL-17, TNF-α, GM-CSF, IFN-γ. The anti-inflammatory cytokines were IL-4 and IL-10, and the MMPs were MMP-2, MMP-3, MMP-7, MMP-9. Protein concentration is reported as pg/mL for each analyte. Results Patient CSF was obtained at the time of shunt revision operation; all pediatric (< 18), totaling n = 38. IL-10, IL-6, IL-8 and MMP-7 demonstrated significantly increased concentrations in patient CSF for the non-obstructed subgroup. Etiological examination revealed IL-6 was increased in both obstructed and non-obstructed cases for PHH and congenital hydrocephalic patients, while IL-8 was higher only in PHH patients. In terms of number of past revisions, IL-10, IL-6, IL-8, MMP-7 and MMP-9 progressively increased from zero to two past revisions and then remained low for subsequent revisions. This presentation was notably absent in the obstruction subgroup. Shunts implanted for three months or less showed significantly increased concentrations of IL-6, IL-8, and MMP-7 in the obstruction subgroup. Lastly, only patients aged six months or less presented with significantly increased concentration of IL-8 and MMP-7. Conclusion Non-obstructive cases are reported here to accompany significantly higher CSF cytokine and MMP protein levels compared to obstructive cases for IL-10, IL-6, IL-8, MMP-7 and MMP-9. A closer examination of the definition of obstruction and the role neuroinflammation plays in creating shunt obstruction in hydrocephalic patients is suggested.

Cerebrospinal fluid edema associated with shunt obstruction

1994 ◽  
Vol 81 (2) ◽  
pp. 179-183 ◽  
Author(s):  
Hiroaki Sakamoto ◽  
Ken Fujitani ◽  
Shouhei Kitano ◽  
Keiji Murata ◽  
Akira Hakuba
Keyword(s):  
Cerebrospinal Fluid ◽  
Subcortical White Matter ◽  
Shunt Revision ◽  
Csf Shunt ◽  
Limited Area ◽  
Ventricular Catheter ◽  
Small Lesion ◽  
Rapid Improvement ◽  
Content Type ◽  
Shunt Obstruction

✓ The authors report four hydrocephalic children with cerebrospinal fluid (CSF) edema extending along the ventricular catheter of an obstructed CSF shunt. Three of the patients exhibited massive CSF edema along the ventricular catheter, yet they manifested neither ventricular enlargement nor apparent periventricular CSF edema despite increased intraventricular pressure. These findings suggested ventricular tautness. The remaining patient, who had dilated ventricles with periventricular CSF edema, displayed CSF edema in a limited area along the ventricular catheter. Replacement of the obstructed peritoneal catheter of the shunt resulted in rapid improvement of the edema in all patients. In the three patients with massive CSF edema, however, a small lesion remained in the subcortical white matter along the ventricular catheter as demonstrated by computerized tomography and/or magnetic resonance imaging 3 to 5 years after shunt revision. It is concluded that shunt obstruction may result in massive CSF edema along the ventricular catheter in hydrocephalic children who have ventricular tautness after installation of the shunt causing irreversible although usually asymptomatic damage to the affected area of the brain.

scholarly journals Current epidemiology of cerebrospinal fluid shunt surgery in the UK and Ireland (2004–2013)

2019 ◽  
Vol 90 (7) ◽  
pp. 747-754 ◽  
Author(s):  
Rocío Fernández-Méndez ◽  
Hugh K Richards ◽  
Helen M Seeley ◽  
John D Pickard ◽  
Alexis J Joannides
Keyword(s):  
Cerebrospinal Fluid ◽  
Intraventricular Haemorrhage ◽  
Normal Pressure ◽  
Incidence Rates ◽  
Shunt Revision ◽  
Csf Shunt ◽  
First Year ◽  
Shunt Surgery ◽  
Potential Risks ◽  
The Uk

ObjectivesTo determine current epidemiology and clinical characteristics of cerebrospinal fluid (CSF) shunt surgery, including revisions.MethodsA retrospective, multicentre, registry-based study was conducted based on 10 years’ data from the UK Shunt Registry, including primary and revision shunting procedures reported between 2004 and 2013. Incidence rates of primary shunts, descriptive statistics and shunt revision rates were calculated stratified by age group, geographical region and year of operation.Results41 036 procedures in 26 545 patients were submitted during the study period, including 3002 infants, 4389 children and 18 668 adults. Procedures included 20 947 (51.0%) primary shunt insertions in 20 947 patients, and 20 089 (49.0%) revision procedures. Incidence rates of primary shunt insertions for infants, children and adults were 39.5, 2.4 and 3.5 shunts per 100 000 person-years, respectively. These varied by geographical subregion and year of operation. The most common underlying diagnoses were perinatal intraventricular haemorrhage (35.3%) and malformations (33.9%) in infants, tumours (40.5%) and malformations (16.3%) in children, and tumours (24.6%), post-haemorrhagic hydrocephalus (16.2%) and idiopathic normal pressure hydrocephalus (14.2%) in adults. Ninety-day revision rates were 21.9%, 18.6% and 12.8% among infants, children and adults, respectively, while first-year revision rates were 31.0%, 25.2% and 17.4%. The main reasons for revision were underdrainage and infection, but overdrainage and mechanical failure continue to pose problems.ConclusionsOur report informs patients, carers, clinicians, providers and commissioners of healthcare, researchers and industry of the current epidemiology of shunting for CSF disorders, including the potential risks of complications and frequency of revision.

Flow characteristics of cerebrospinal fluid shunt tubing

2012 ◽  
Vol 9 (2) ◽  
pp. 191-197 ◽  
Author(s):  
Joseph T. Cheatle ◽  
Alexis N. Bowder ◽  
Sandeep K. Agrawal ◽  
Michael D. Sather ◽  
Leslie C. Hellbusch
Keyword(s):  
Cerebrospinal Fluid ◽  
Flow Characteristics ◽  
Hydrodynamic Resistance ◽  
Csf Shunt ◽  
Effective Diameter ◽  
Cerebrospinal Fluid Shunt ◽  
Shunt System ◽  
Shunt Valve ◽  
Cross Sectional ◽  
Distal Catheter

Object Cerebrospinal fluid shunt systems malfunction for a multitude of reasons, including malpostitioning, obstruction of the ventricular or distal catheter, obstruction of the shunt valve, and catheter disruptions or disconnections. The goal of this study was to examine the hydrodynamic resistance and flow in new and explanted catheters and also in catheters with 1 or 2 straight connectors. Methods Explanted catheters of multiple lengths, 2-piece catheters, 3-piece catheters, and new catheters were attached to a proximal and distal manometer. A flask with artificial CSF attached to the proximal end provided flow. The flow was allowed to stabilize over 1 hour; then the change in pressure between the proximal and distal end of the catheter was measured. Results The resistance to flow was calculated for new, never-implanted catheters and compared with the resistance of explanted distal shunt catheters. The resistance of the new catheters was examined after the addition of 1 and 2 straight connectors. Explanted catheters exhibited a slight increase in the resistance to flow of artificial CSF compared with new catheters. Two-piece and 3-piece catheters had a significant increase in resistance to flow compared with new catheters. For all catheters, resistance to flow increased as length increased (new, p = 0.01; explanted, p = 0.009; 1 connector, p = 0.01; 2 connectors, p = 0.03). In this paper, effective diameter is defined as the available cross-sectional area of catheter contacted by the artificial CSF. For new and explanted catheters, a decrease in the effective diameter of the catheter was associated with an increase in the resistance to flow of artificial CSF (new, p = 0.1083; explanted, p = 0.0091). However, after the addition of 1 or 2 connectors, an inverse trend was observed: resistance to flow increased with effective diameter. Conclusions There appears to be some increase in resistance of CSF shunt catheters as they age, altering flow dynamics. In addition, the use of straight connectors within a CSF shunt system increases the resistance to flow of artificial CSF within the shunt system. The increase in resistance appears to be related to the duration of implantation and the length of the catheter and inversely related to the diameter of the catheter. This increase in resistance may be related to sterile shunt malfunction. The addition of straight connectors is associated with a significant increase in resistance in comparison with catheters without connectors (p = 0.005).

Cerebrospinal Fluid Shunts

2018 ◽  
Author(s):  
Jinu Kim ◽  
Aleka Scoco
Keyword(s):  
Cerebrospinal Fluid ◽  
Cerebral Perfusion ◽  
Anesthetic Management ◽  
Flow Dynamics ◽  
Western Society ◽  
Csf Shunt ◽  
Cerebrospinal Fluid Shunts ◽  
Csf Flow ◽  
Neurosurgical Procedure ◽  
Adults And Children

Placement and revision of ventricular shunts has saved more lives in Western society than any other neurosurgical procedure. Estimates of a total of 75,000 shunt procedures are done yearly in North America. The majority of these cerebrospinal fluid (CSF)-diverting shunts originate in the lateral ventricle, drain into the peritoneum and are described as ventriculoperitoneal (VP) shunts. Other less common CSF shunt variants include ventriculoatrial and ventriculopleural. VP shunts are the most common neurosurgical procedure performed in both adults and children. An understanding of CSF flow dynamics, intracranial pressure, and cerebral perfusion helps guide anesthetic management of these procedures.

scholarly journals Test characteristics of neuroimaging in the emergency department evaluation of children for cerebrospinal fluid shunt malfunction

CJEM ◽  
2008 ◽  
Vol 10 (02) ◽  
pp. 131-135 ◽  
Author(s):  
Ahmed Mater ◽  
Manohar Shroff ◽  
Sami Al-Farsi ◽  
James Drake ◽  
Ran D. Goldman
Keyword(s):  
Emergency Department ◽  
Cerebrospinal Fluid ◽  
Ct Scan ◽  
Likelihood Ratio ◽  
Predictive Value ◽  
Tertiary Care ◽  
Shunt Malfunction ◽  
Shunt Revision ◽  
Csf Shunt ◽  
Test Characteristics

ABSTRACT Objective: Cerebrospinal fluid (CSF) shunt malfunction is one of the most common life-threatening neurosurgical conditions. In the emergency department (ED), imaging techniques to identify shunt malfunction include the shunt series (SS) and CT scanning of the head. We sought to determine the test characteristics of the SS and CT scan for identifying children with shunt malfunction. Methods: We retrospectively reviewed the medical records of children with a CSF shunt who presented to our tertiary care pediatric emergency department and received an SS during a 2-year period from Jan. 1, 2001, to Dec. 31, 2002. A pediatric neuroradiologist reviewed all SS and CT scans. We defined shunt malfunction as present if the child underwent operative shunt revision. Results: We identified 437 ED visits by 280 children. Forty-seven SS were read as abnormal. A CT scan was performed in 386 (88.3%) cases and 80 were abnormal. Shunt malfunction was identified in 131 (30.0%) children. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio of the SS for identifying cases of shunt malfunction were 30.0%, 95.8%, 72.3%, 75.1%, 7.1 and 0.7, respectively; for the CT scan, they were 61.0%, 82.7%, 64.5%, 80.5%, 3.5 and 0.5, respectively. Conclusion: Neuroimaging has a low sensitivity for identifying shunt malfunction. Neurosurgical consultation should be sought if shunt malfunction is clinically suspected, despite normal imaging.

Increased risk of distal ventriculoperitoneal shunt obstruction associated with slit valves or distal slits in the peritoneal catheter

1997 ◽  
Vol 87 (5) ◽  
pp. 682-686 ◽  
Author(s):  
Jeffrey W. Cozzens ◽  
James P. Chandler
Keyword(s):  
Shunt Revision ◽  
Ventricular Catheter ◽  
Peritoneal Catheter ◽  
Distal Catheter ◽  
Content Type ◽  
Vp Shunt ◽  
Increased Risk ◽  
Catheter Obstruction ◽  
Shunt Obstruction ◽  
Fine Print

✓ The authors describe a relationship between the presence of distal shunt catheter side-wall slits and distal catheter obstruction in a single-surgeon series of ventriculoperitoneal (VP) shunt revisions. Between 1985 and 1996, 168 operations for VP shunt revision were performed by the senior author (J.W.C.) in 71 patients. Indications for shunt revision included obstruction in 140 operations; overdrainage or underdrainage requiring a change of valve in 17 operations; inadequate length of distal shunt tubing resulting in the distal end no longer reaching the peritoneum in five operations; the ventricular catheter in the wrong ventricle or space, requiring repositioning in five operations; and a disconnected or broken shunt in one operation. Of the 140 instances of shunt obstruction, the blockage occurred at the ventricular end in 108 instances (77.1%), the peritoneal end in 17 (12.1%), the ventricular and the peritoneal end in 14 (10%), and in the valve mechanism (not including distal slit valves) in one (0.8%). Thus, the peritoneal end was obstructed in 31 (22.1%) of 140 cases of shunt malfunction. In every case in which the peritoneal end was obstructed, some form of distal slit was found: either a distal slit valve in an otherwise closed catheter or slits in the side of an open catheter. No instances were found of distal peritoneal catheter obstruction when the peritoneal catheter was a simple open-ended tube with no accompanying side slits (0 of 55). It is concluded that side slits in the distal peritoneal catheters of VP shunts are associated with a greater incidence of distal shunt obstruction.

Pregnancy in Patients with Cerebrospinal Fluid Shunts: Report of a Series and Review of the Literature

Neurosurgery ◽  
1991 ◽  
Vol 29 (6) ◽  
pp. 827-831 ◽  
Author(s):  
Jeffrey H. Wisoff ◽  
Kristen J. Kratzert ◽  
Sara M. Handwerker ◽  
Bruce K. Young ◽  
Fred Epstein
Keyword(s):  
Cerebrospinal Fluid ◽  
Magnetic Resonance ◽  
Neurological Complications ◽  
Magnetic Resonance Images ◽  
Reproductive Age ◽  
Shunt Revision ◽  
Cerebrospinal Fluid Shunts ◽  
Perinatal Complications ◽  
Second Stage ◽  
Shunt Obstruction

Abstract Hydrocephalic women with cerebrospinal fluid shunts are now surviving to reproductive age. Twenty-one pregnancies in 18 patients with shunts, including 11 from the present series and 10 from previous series, were analyzed for neurological, obstetrical, and perinatal outcome. Fourteen women had preexisting shunts, and 4 had the onset of symptomatic hydrocephalus and the placement of shunts during pregnancy. Neurological complications occurred in 13 of 17 (76%) pregnancies in patients with preexisting shunts, including symptoms of increased intracranial pressure (ICP) in 10 of 17 (59%) pregnancies, exacerbation of seizure disorder in 2 of 17 (12%) pregnancies, and severe headaches without increased ICD in 1 patient. In 7 of 11 (66%) of the symptomatic patients, symptoms spontaneously resolved postpartum. Four of 17 (23%) of these pregnancies were associated with shunt obstruction requiring antepartum or postpartum surgery. Four patients had a primary shunt placement, and one had a shunt revision during pregnancy without complications. There were no unusual obstetrical or perinatal complications in the series. The clinical management of pregnant patients with hydrocephalus should include preconception counseling and magnetic resonance imaging, as well as the use of serial antenatal magnetic resonance images, ICP monitoring, or the judicious use of radioisotope studies of shunt patency if signs of increased ICP appear. A cesarean section is recommended for the delivery of the neurologically unstable patient. For asymptomatic mothers, a vaginal delivery with a shortened second stage and prophylactic antibiotics are advised.

THERAPY OF STAPHYLOCOCCUS EPIDERMIDIS: INFECTIONS ASSOCIATED WITH CEREBROSPINAL FLUID SHUNTS

PEDIATRICS ◽  
1974 ◽  
Vol 53 (1) ◽  
pp. 55-62
Author(s):  
David B. Shurtleff ◽  
Eldon L. Foltz ◽  
Robert D. Weeks ◽  
John Loeser
Keyword(s):  
Cerebrospinal Fluid ◽  
Staphylococcus Epidermidis ◽  
Systemic Treatment ◽  
Complete Removal ◽  
Shunt Revision ◽  
Cerebrospinal Fluid Shunts ◽  
Anatomic Site ◽  
Complete Replacement ◽  
Systemic Antibiotic Therapy ◽  
Cure Rates

This study describes cure rates for 93 different courses of treatment for 28 hydrocephalic patients with V-A shunts and 31 separate infections due to Staphylococcus epidermidis. Systemic treatment alone was effective two out of 39 times (9%). The addition of antibiotics via the intraventricular route (with or without partial shunt revision) cured three with nine trials (33%). All 19 patients, 18 with positive cerebrospinal fluid (CSF) cultures, were cured by complete removal of all shunt elements with replacement in another anatomic site (CSR) combined with high does, specific systemic antibiotic therapy. One of 35 (3%) of those with positive shunt CSF cultures and one of 21 (5%) of those with positive shunt and ventricular CSF cultures responded to systemic treatment without CSR. When infection is widespread, the treatment of choice is appropriate systemic and intraventricular antibiotics and complete replacement of the shunt in a new site.

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