Diverse Clinical Applications of Percutaneous Lumboperitoneal Shunts

Abstract A population of 28 patients underwent the percutaneous placement of a shunt in the lumbar region with a single tube, the other end of which was placed in the peritoneal cavity by laparotomy. The clinical indications for the procedure were: communicating hydrocephalus (16 patients), pseudotumor cerebri (3 patients), cranial cerebrospinal fluid fistula (4 patients), and a bulging postcraniotomy site (2 patients). An additional 3 patients were treated by lumbar subcutaneousperitoneal shunt for a cerebrospinal fluid (CSF)-subcutaneous fistula after the removal of a leptomyelolipoma. The mean time of follow-up was 18.8 ± 7.8 months. All patients with pseudotumor cerebri and subcutaneous lumbar CSF fistula and all but 1 of the patients with a cranial CSF fistula improved without further therapy. Twelve of the 16 patients with communicating hydrocephalus improved and did not require other shunt procedures. There was one shunt infection, one wound dehiscence that led to shunt removal, and one shunt migration into the spinal canal. Shunt obstruction that led to revision of the shunt occurred on three occasions in 2 patients. The shunt functioned in only 1 of 4 infants under 4 months of age.

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Cerebrospinal fluid shunt placement for pseudotumor cerebri—associated intractable headache: predictors of treatment response and an analysis of long-term outcomes

Journal of Neurosurgery ◽

10.3171/jns.2004.101.4.0627 ◽

2004 ◽

Vol 101 (4) ◽

pp. 627-632 ◽

Cited By ~ 152

Author(s):

Matthew J. Mcgirt ◽

Graeme Woodworth ◽

George Thomas ◽

Neil Miller ◽

Michael Williams ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Pseudotumor Cerebri ◽

Shunt Revision ◽

Csf Shunts ◽

Content Type ◽

Shunt Placement ◽

Increased Risk ◽

Shunt Obstruction ◽

Fine Print

Object. Cerebrospinal fluid (CSF) shunts effectively reverse symptoms of pseudotumor cerebri postoperatively, but long-term outcome has not been investigated. Lumboperitoneal (LP) shunts are the mainstay of CSF shunts for pseudotumor cerebri; however, image-guided stereotaxy and neuroendoscopy now allow effective placement of a ventricular catheter without causing ventriculomegaly in these cases. To date it remains unknown if CSF shunts provide long-term relief from pseudotumor cerebri and whether a ventricular shunt is better than an LP shunt. The authors investigated these possibilities. Methods. The authors reviewed the records of all shunt placement procedures that were performed for intractable headache due to pseudotumor cerebri at one institution between 1973 and 2003. Using proportional hazards regression analysis, predictors of treatment failure (continued headache despite a properly functioning shunt) were assessed, and shunt revision and complication rates were compared between LP and ventricular (ventriculoperitoneal [VP] or ventriculoatrial [VAT]) shunts. Forty-two patients underwent 115 shunt placement procedures: 79 in which an LP shunt was used and 36 in which a VP or VAT shunt was used. Forty patients (95%) experienced a significant improvement in their headaches immediately after the shunt was inserted. Severe headache recurred despite a properly functioning shunt in eight (19%) and 20 (48%) patients by 12 and 36 months, respectively, after the initial shunt placement surgery. Seventeen patients without papilledema and 19 patients in whom preoperative symptoms had occurred for longer than 2 years experienced recurrent headache, making patients with papilledema or long-term symptoms fivefold (relative risk [RR] 5.2, 95% confidence interval [CI] 1.5–17.8; p < 0.01) or 2.5-fold (RR 2.51, 95% CI 1.01–9.39; p = 0.05) more likely to experience headache recurrence, respectively. In contrast to VP or VAT shunts, LP shunts were associated with a 2.5-fold increased risk of shunt revision (RR 2.5, 95% CI 1.5–4.3; p < 0.001) due to a threefold increased risk of shunt obstruction (RR 3, 95% CI 1.5–5.7; p < 0.005), but there were similar risks between the two types of shunts for overdrainage (RR 2.3, 95% CI 0.8–7.9; p = 0.22), distal catheter migration (RR 2.1, 95% CI 0.3–19.3; p = 0.55), and shunt infection (RR 1.3, 95% CI 0.3–13.2; p = 0.75). Conclusions. Based on their 30-year experience in the treatment of these patients, the authors found that CSF shunts were extremely effective in the acute treatment of pseudotumor cerebri—associated intractable headache, providing long-term relief in the majority of patients. Lack of papilledema and long-standing symptoms were risk factors for treatment failure. The use of ventricular shunts for pseudotumor cerebri was associated with a lower risk of shunt obstruction and revision than the use of LP shunts. Using ventricular shunts in patients with papilledema or symptoms lasting less than 2 years should be considered for those with pseudotumor cerebri—associated intractable headache.

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Role of endoscopic third ventriculostomy at infected cerebrospinal fluid shunt removal

Journal of Neurosurgery Pediatrics ◽

10.3171/2011.12.peds11229 ◽

2012 ◽

Vol 9 (3) ◽

pp. 320-326 ◽

Cited By ~ 18

Author(s):

Tomohisa Shimizu ◽

Mark G. Luciano ◽

Toru Fukuhara

Keyword(s):

Risk Factors ◽

Cerebrospinal Fluid ◽

Endoscopic Third Ventriculostomy ◽

Shunt Infection ◽

Secondary Outcome ◽

Csf Shunt ◽

Third Ventriculostomy ◽

Cerebrospinal Fluid Shunt ◽

Csf Shunts ◽

Shunt Removal

Object Cerebrospinal fluid shunt infection is distressing, especially in the pediatric population. Usually, infected CSF shunts are removed, and after temporary external CSF drainage, reinsertion of the CSF shunt is necessary. Unfortunately, it is not rare to encounter CSF reinfection after shunt renewal, and furthermore, the reinserted CSF shunt is at a considerable risk of malfunction. Endoscopic third ventriculostomy (ETV) is a potent option in managing CSF shunt infection, although ETV failure may occur more frequently when it is used to remove an infected shunt. The authors retrospectively evaluated CSF reinfection after using ETV during removal of infected CSF shunts; then the longevity of ETV and of successive reinserted ventriculoperitoneal shunts (VPSs) after ETV failure were also examined. Methods Children with shunted hydrocephalus were retrospectively reviewed, and data on their initial CSF shunt infections were extracted. Thirty-six children underwent VPS reinsertion (the VPS group), and 9 underwent ETV after removal of the infected CSF shunt (the ETV group). As the primary outcome, ETV efficacy against CSF reinfection within 6 months was analyzed by comparing the reinfection rates, and the risk factors for CSF reinfection were analyzed by logistic regression. The longevity of the reinserted shunt in the VPS group was calculated using the Kaplan-Meier method, which was compared with ETV longevity as the secondary outcome, and also with the longevity of reinserted VPSs in the ETV group after ETV failure as the tertiary outcome. Results Reinfection of CSF was seen in 27.8% of children in the VPS group. Among 9 children in the ETV group, only 1 (11.1%) had CSF reinfection. However, logistic regression analysis failed to show that performing ETV was a significant factor protecting against CSF reinfection: the significant risk factors were younger age at reinsertion of VPS or ETV (p = 0.037) and a history of shunt revisions (p = 0.011). The longevity of reinserted VPSs in the VPS group was calculated to be 658 ± 166.3 days (mean ± SE). Longevity of ETV was compared in the analysis of the secondary outcome, which was 929.2 ± 511.1 days, and there were no significant differences between these durations. Only 2 ETVs stayed patent, and a VPS was eventually implanted in the other 7 children. The longevity of this reinserted VPS in the ETV group, calculated based on these 7 children, was 2011.1 ± 540.7 days, which was confirmed to be longer than that in the VPS group (p = 0.031). Conclusions Although the protective effect of using ETV during removal of an infected CSF shunt on reinfection is marginal, the ETV longevity can be considered equivalent to that of reinserted VPSs. Even if ETV failure occurs, the reinserted VPS has significantly better longevity than a VPS reinserted without using ETV, and use of ETV during infected CSF shunt removal can be considered a potent alternative or at least an adjunct to VPS reinsertion.

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Effect of Antibiotic-Impregnated Shunts on Infection Rate in Adult Hydrocephalus: A Single Institution's Experience

Neurosurgery ◽

10.1227/neu.0b013e31821bc435 ◽

2011 ◽

Vol 69 (3) ◽

pp. 625-629 ◽

Cited By ~ 12

Author(s):

S Harrison Farber ◽

Scott L Parker ◽

Owoicho Adogwa ◽

Matthew J McGirt ◽

Daniele Rigamonti

Keyword(s):

Normal Pressure ◽

Pseudotumor Cerebri ◽

Shunt Infection ◽

Csf Shunt ◽

Communicating Hydrocephalus ◽

Shunt Insertion ◽

Oxacillin Resistance ◽

Catheter Implantation ◽

Csf Shunt Infection ◽

The Mean

Abstract BACKGROUND: Cerebrospinal fluid (CSF) shunt infection remains a major cause of morbidity and mortality in the treatment of hydrocephalus. Studies have demonstrated the efficacy of antibiotic-impregnated shunt (AIS) systems in reducing CSF shunt infections in pediatric patients. Fewer studies evaluate the efficacy of AIS systems in adult hydrocephalus. OBJECTIVE: To determine whether categorical conversion to AIS shunt systems reduced the incidence of shunt infection in adults. METHODS: All adult patients undergoing CSF shunt insertion over a 7-year period were retrospectively reviewed (2004–2009). In 2006, a categorical switch to AIS catheters was made. Before 2006, standard nonimpregnated shunt catheters were used. We retrospectively reviewed the first 250 cases of AIS catheter implantation and compared them with the immediately preceding 250 non-AIS cases to assess 1-year incidence of CSF shunt infection. RESULTS: Five hundred shunt surgeries were performed for normal-pressure hydrocephalus in 378 patients (76%), pseudotumor cerebri in 83 patients (17%), and various obstructive/communicating hydrocephalus etiologies in 40 patients (8%). All patients were followed for 12 months. The mean age was 60 ± 18 years. Baseline characteristics were similar between AIS (n = 250) and non-AIS (n = 250) cohorts. Overall, 13 patients (2.6%) experienced CSF shunt infection, occurring a mean of 2 ± 2 months postoperatively. Shunt infection incidence was decreased in AIS (1.2%) vs non-AIS (4.0%) cohorts (P = .0492). Staphylococcus epidermidis was the most common pathogen in AIS and non-AIS cohorts. Oxacillin resistance was not increased in the AIS cohort. CONCLUSION: Categorical conversion to AIS catheters was associated with a reduced incidence of shunt infection. AIS catheters may be a reliable instrument for decreasing perioperative shunt colonization and subsequent infection in adults with hydrocephalus.

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Treatment of Cerebrospinal Fluid Rhinorrhea by Percutaneous Lumboperitoneal Shunting: Review of 15 cases

Neurosurgery ◽

10.1097/00006123-198501000-00009 ◽

1985 ◽

Vol 16 (1) ◽

pp. 44-47 ◽

Cited By ~ 1

Author(s):

Philippe Bret ◽

Frédéric Hor ◽

Claude Lapras ◽

Georges Fischer

Keyword(s):

Cerebrospinal Fluid ◽

Direct Methods ◽

Csf Leak ◽

Communicating Hydrocephalus ◽

Benign Intracranial Hypertension ◽

Cerebrospinal Fluid Rhinorrhea ◽

Computed Tomographic ◽

Additional Surgery ◽

Shunt Removal ◽

Spinal Catheter

Abstract Fifteen patients with recalcitrant cerebrospinal fluid (CSF) fistula underwent the insertion of a lumboperitoneal shunt. The shunt consists of a two-piece Silastic tube and has been used in a population of 150 patients with communicating hydrocephalus, persistent postoperative meningocele, and benign intracranial hypertension. The spinal catheter is introduced subcutaneously and no flushing device is used. We studied three groups: 9 patients had a history of head trauma, and 7 of these had undergone one or several ineffective direct approaches to the dural leak. Four patients presented with a presumably congenital fistula. Two patients had persistent rhinorrhea due to previous intracranial procedures. Indium-111 cisternography was performed in 10 patients before lumboperitonel (LP) shunting and failed in 2 of those to document the site of leakage. Twelve patients showed cessation of rhinorrhea after LP shunting. In 4 of these, shunt-related complications responded to shunt removal with no further recurrence of rhinorrhea. Two patients underwent revision of the shunt. In 3 patients, the LP shunt failed to control the CSF leak and further intracranial procedures were indicated. The LP shunt provides and attractive and technically simple solution when direct methods of treatment have failed. Additionally, LP shunting should be considered as a primary mode of treatment in elderly patients or when impairment of CSF dynamics is documented by radionuclide cisternography and computed tomographic scanning. When an LP shunt is ineffective, shunt function should be checked by isotopic studies before additional surgery is performed. (Neurosurgery 16:44–47, 1985)

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Factors causing acute shunt infection

Journal of Neurosurgery ◽

10.3171/jns.1984.61.6.1072 ◽

1984 ◽

Vol 61 (6) ◽

pp. 1072-1078 ◽

Cited By ~ 145

Author(s):

Dominique Renier ◽

Jacques Lacombe ◽

Alain Pierre-Kahn ◽

Christian Sainte-Rose ◽

Jean-François Hirsch

Keyword(s):

Wound Dehiscence ◽

Shunt Infection ◽

Ventricular Catheter ◽

Content Type ◽

Significant Relationships ◽

Shunt Procedure ◽

Scalp Necrosis ◽

Shunt Removal ◽

Neurosurgical Operation ◽

Fine Print

✓ A series of 1174 operations performed on 802 hydrocephalic children was analyzed in an effort to find the factors causing acute postoperative infection. Culture of the cerebrospinal fluid (CSF) samples during the operation was positive in 33 cases. These cases were excluded from the series. Ninety infections were observed in the remaining 1141 operations, an overall rate of 7.9%. Most of these infections were meningitis (56 cases). Staphylococcus epidermidis was the bacterium most frequent identified (44%). Statistically significant relationships were found between shunt infection and the following factors: 1) age: infection was 2.6 times as frequent before 6 months than after 1 year of age (p = 0.03); 2) poor condition of the skin; 3) presence of intercurrent seats of infection at the time of surgery; 4) type of operation: the rate of infection was 8.4% in primary shunt insertions, 5% in shunt revisions, and 17.5% in reinsertions following shunt removal for infection (p = 0.0001); 5) end of the shunt requiring revision: an infection rate of 7.7% followed revision of the ventricular catheter alone, and 2.6% followed revision of the other end alone (p = 0.012); and 6) postoperative wound dehiscence or scalp necrosis. The surgical team involved was poorly correlated with the rate of infection (p = 0.12). No statistically significant relationships have been found between infection and 1) etiology of hydrocephalus; 2) sex; 3) recent neurosurgical operation before the shunt procedure; 4) preoperative presence of an external drainage tube or CSF fistula; 5) lumbar or ventricular taps, or ventriculography; 6) number of previous operations performed on the shunt; 7) time (month and year) of operation; or 8) sugar level and cell count in the CSF.

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Distant large acute epidural hematoma after closed cerebrospinal fluid tapping through the anterior fontanelle: A case report and its pathogenesis

Surgical Neurology International ◽

10.25259/sni_921_2020 ◽

2021 ◽

Vol 12 ◽

pp. 59

Author(s):

Ahmed A. M. Ezzat ◽

Mohamed A. R. Soliman ◽

Mohammad Baraka ◽

Mohamed El Shimy ◽

Adham Ezz ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Epidural Hematoma ◽

Shunt Infection ◽

External Ventricular Drainage ◽

Csf Shunt ◽

Anterior Fontanelle ◽

Patient Death ◽

Conscious Level ◽

Shunt Removal ◽

Acute Epidural Hematoma

Background: Cerebrospinal fluid (CSF) infection is one of the most common and serious complications of shunt placement. The CSF shunt infections are preferably treated with intravenous antibiotics, infected shunt removal, repeated tapping (infants) or placement of an external ventricular drainage (EVD) device, and placement of a new shunt once the CSF is sterile. The tapping through the anterior fontanelle is commonly used instead of the EVD in developing countries to manage CSF infection in open anterior fontanelle patients. To the best of our knowledge, this would be considered the first reported case of distant epidural hematoma after closed ventricular tapping. Case Description: We report a case of 6-months child with Chiari malformation (Type II) presenting to us with a shunt infection with possible obstruction. CSF was aspirated for examination through a tap through the anterior fontanelle followed by the development of extradural hemorrhage far from the tapping site. Conclusion: EDH after a transfontanellar ventricular tap can rapidly evolve and lead to patient death. This report raises the awareness of the neurosurgeons to this possible complication that can happen and leads to major complications. Monitoring the conscious level would be needed after ventricular tapping to detect this possible complication.

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A Familial Coincidence of Pseudotumor Cerebri and Communicating Hydrocephalus

Neurosurgery ◽

10.1227/00006123-199105000-00016 ◽

1991 ◽

Vol 28 (5) ◽

pp. 727-729 ◽

Cited By ~ 12

Author(s):

Ian Johnston ◽

Michael K. Morgan

Keyword(s):

Cerebrospinal Fluid ◽

Intracranial Hypertension ◽

Pseudotumor Cerebri ◽

The Other ◽

Communicating Hydrocephalus ◽

Fluid Absorption ◽

Cerebrospinal Fluid Absorption ◽

History Of

Abstract A family in which the mother and two of four daughters had a diagnosis of pseudotumor cerebri and one son developed communicating hydrocephalus is described. The other two daughters both have a long history of headaches but no signs of intracranial hypertension. The argument is advanced that there exists a defect of cerebrospinal fluid absorption common to pseudotumor cerebri and communicating hydrocephalus.

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Resistance to Outflow of Cerebrospinal Fluid Determined by Bolus Injection Technique and Constant Rate Steady State Infusion in Humans

Neurosurgery ◽

10.1227/00006123-198503000-00010 ◽

1985 ◽

Vol 16 (3) ◽

pp. 336-340 ◽

Cited By ~ 28

Author(s):

Michael Kosteljanetz

Keyword(s):

Cerebrospinal Fluid ◽

Steady State ◽

Bolus Injection ◽

Point Of View ◽

Injection Technique ◽

Communicating Hydrocephalus ◽

Constant Rate ◽

High Degree ◽

Infusion Technique

Abstract Two methods for the determination of resistance to the outflow of cerebrospinal fluid, the bolus injection technique and the constant rate steady state infusion technique, were compared. Thirty-two patients with a variety of intracranial diseases (usually communicating hydrocephalus) were studied. There was a high degree of correlation between the resistance values obtained with the two methods, but values based on the bolus injection technique were systematically and statistically significantly lower than those obtained with the constant rate infusion test. From a practical point of view. both methods were found to be applicable in a clinical setting.

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