scholarly journals Reconsidering Ventriculoperitoneal Shunt Surgery and Postoperative Shunt Valve Pressure Adjustment: Our Approaches Learned From Past Challenges and Failures

2022 ◽  
Vol 12 ◽  
Author(s):  
Shigeki Yamada ◽  
Masatsune Ishikawa ◽  
Madoka Nakajima ◽  
Kazuhiko Nozaki
Keyword(s):  
Ventriculoperitoneal Shunt ◽  
Early Period ◽  
Csf Shunt ◽  
Symptom Improvement ◽  
Shunt Surgery ◽  
Shunt Valve ◽  
Improvement Rate ◽  
Shunt Implantation ◽  
Csf Drainage ◽  
Valve Pressure

Treatment for idiopathic normal pressure hydrocephalus (iNPH) continues to develop. Although ventriculoperitoneal shunt surgery has a long history and is one of the most established neurosurgeries, in the 1970s, the improvement rate of iNPH triad symptoms was poor and the risks related to shunt implantation were high. This led experts to question the surgical indication for iNPH and, over the next 20 years, cerebrospinal fluid (CSF) shunt surgery for iNPH fell out of favor and was rarely performed. However, the development of programmable-pressure shunt valve devices has reduced the major complications associated with the CSF drainage volume and appears to have increased shunt effectiveness. In addition, the development of support devices for the placement of ventricular catheters including preoperative virtual simulation and navigation systems has increased the certainty of ventriculoperitoneal shunt surgery. Secure shunt implantation is the most important prognostic indicator, but ensuring optimal initial valve pressure is also important. Since over-drainage is most likely to occur in the month after shunting, it is generally believed that a high initial setting of shunt valve pressure is the safest option. However, this does not always result in sufficient improvement of the symptoms in the early period after shunting. In fact, evidence suggests that setting the optimal valve pressure early after shunting may cause symptoms to improve earlier. This leads to improved quality of life and better long-term independent living expectations. However, in iNPH patients, the remaining symptoms may worsen again after several years, even when there is initial improvement due to setting the optimal valve pressure early after shunting. Because of the possibility of insufficient CSF drainage, the valve pressure should be reduced by one step (2–4 cmH2O) after 6 months to a year after shunting to maximize symptom improvement. After the valve pressure is reduced, a head CT scan is advised a month later.

CEREBROSPINAL FLUID DRAINAGE AND DYNAMICS IN THE DIAGNOSIS OF NORMAL PRESSURE HYDROCEPHALUS

Neurosurgery ◽  
2009 ◽  
Vol 64 (5) ◽  
pp. 919-926 ◽  
Author(s):  
Graeme F. Woodworth ◽  
Matthew J. McGirt ◽  
Michael A. Williams ◽  
Daniele Rigamonti
Keyword(s):  
Cerebrospinal Fluid ◽  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Waveform Analysis ◽  
Csf Shunt ◽  
Symptom Improvement ◽  
Wave Characteristics ◽  
Csf Drainage ◽  
Ventriculoperitoneal Shunting ◽  
Csf Shunting

Abstract INTRODUCTION Because of the difficulty in distinguishing idiopathic normal pressure hydrocephalus (INPH) from other neurodegenerative conditions unrelated to cerebrospinal fluid (CSF) dynamics, response to CSF shunting remains highly variable. We examined the utility of CSF drainage and CSF pressure (Pcsf) dynamics in predicting response to CSF shunting for patients with INPH. METHODS Fifty-one consecutive INPH patients underwent continuous lumbar Pcsf monitoring for 48 hours followed by 72 hours of slow CSF drainage before ventriculoperitoneal shunting. Response to CSF drainage and B-wave characteristics were assessed via multivariate proportional-hazards regression analysis. RESULTS Improvement in 1, 2, or all 3 INPH symptoms was observed in 35 (69%), 28 (55%), and 11 (22%) patients, respectively, after CSF shunt implantation by 12 months after surgery. A positive response to CSF drainage was found to be an independent predictor of shunt responsiveness (relative risk, 0.30; 95% confidence interval, 0.09–0.98; P = 0.05). There was no difference in Pcsf wave characteristics between the shunt-responsive and -nonresponsive groups, regardless of whether 1-, 2-, or 3-symptom improvement was used to define response to CSF shunting. CONCLUSION In this study of 51 INPH patients who underwent Pcsf monitoring with waveform analysis and CSF drainage followed by shunt surgery, there was no correlation between specific Pcsf wave characteristics and objective symptomatic improvement after shunt placement. Pcsf monitoring with B-wave analysis contributes little to the diagnostic dilemma with INPH patients. Clinical response to continuous CSF drainage over a 72-hour period suggests a high likelihood of shunt responsiveness.

An Update on Programmable CSF Shunt Valves: Identification, MR Imaging Safety and Potential Pitfalls

Neurographics ◽  
2020 ◽  
Vol 10 (1) ◽  
pp. 26-32
Author(s):  
J.E. Costello ◽  
U.A. Rassner
Keyword(s):  
Mr Imaging ◽  
Valve Replacement ◽  
Shunt Revision ◽  
Csf Shunt ◽  
Shunt Valve ◽  
Radiographic Appearance ◽  
Csf Drainage ◽  
Valve Function ◽  
Programmable Devices ◽  
Potential Interactions

Programmable shunt valves are commonly used devices for the treatment of hydrocephalus. Unlike fixed shunt valves, programmable devices allow the operator to alter the amount of CSF drainage without the need for shunt revision or valve replacement. With their increased use, many different programmable shunt valves have been developed by various manufacturers; each programmable shunt valve has a distinct radiographic appearance and CSF drainage setting. Because of potential interactions with MR imaging scanners, which can alter programmable shunt valve function, understanding and accurately reporting these devices is essential.Learning Objectives: Identify commonly used programmable shunt valves and understand their CSF drainage settings to enable the detection of device alterations after MR imaging scanning.

scholarly journals Timed up and go test at tap test and shunt surgery in idiopathic normal pressure hydrocephalus

2017 ◽  
Vol 7 (2) ◽  
pp. 98-108 ◽  
Author(s):  
Shigeki Yamada ◽  
Masatsune Ishikawa ◽  
Masakazu Miyajima ◽  
Madoka Nakajima ◽  
Masamichi Atsuchi ◽  
...  
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Ventriculoperitoneal Shunt ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Shunt Surgery ◽  
Timed Up And Go ◽  
Tap Test ◽  
Lumboperitoneal Shunt ◽  
Shunt Implantation ◽  
Percent Improvement

AbstractBackground:The 3-meter Timed Up and Go test (TUG) is a reliable quantitative test for assessment of gait and balance. We aimed to establish an optimal threshold of TUG at the tap test for predicting outcomes 12 months after shunt surgery in patients with idiopathic normal pressure hydrocephalus (iNPH).Methods:The TUG was measured in a total of 151 patients with possible iNPH before and after a tap test and 12 months after shunt surgery. Among them, 81 patients underwent ventriculoperitoneal shunt implantation (SINPHONI) and 70 underwent lumboperitoneal shunt implantation (SINPHONI-2). The areas under the curve (AUCs), sensitivities, and specificities for predicting shunt effectiveness were assessed.Results:The simple differences of time on TUG at the tap test were significantly more accurate for predicting shunt effectiveness than percent improvement of time. The highest AUC for the synchronized moving cutoff point of TUG time was 0.81 (sensitivity 81.0%; specificity 81.6%) at the threshold of 5 seconds in the SINPHONI-2. For predicting improvements of ≥10 seconds 12 months after lumboperitoneal shunt implantation, the AUC was 0.90, and the sensitivity and specificity at the threshold of 5.6 seconds were 83.3% and 81.0%. Only for patients with a <5-second improvement at the tap test, ventriculoperitoneal shunt implantation conveyed significantly better improvements in TUG time 12 months after surgery than lumboperitoneal shunt implantation.Conclusions:An improvement of 5 seconds was a useful threshold of TUG time at the tap test for predicting a ≥10-second improvement 12 months after shunt surgery, rather than the percent improvement of TUG time.

Serum and Cerebrospinal Fluid Vancomycin and Gentamicin Concentrations during Ventriculoperitoneal Shunt Surgery: An Observational Study

2000 ◽  
Vol 16 (4) ◽  
pp. 155-160 ◽  
Author(s):  
Walter J Faillace ◽  
Paul Tan
Keyword(s):  
Cerebrospinal Fluid ◽  
Observational Study ◽  
Infection Rate ◽  
Ventriculoperitoneal Shunt ◽  
Control Measures ◽  
University Hospital ◽  
Csf Shunt ◽  
Shunt Surgery ◽  
Serum Concentrations ◽  
Period Range

Background: Ventriculoperitoneal shunts become infected predominantly during surgery. Optimal antibiotic prophylaxis during cerebrospinal fluid (CSF) shunt surgery has not been fully determined. Objective: To quantitate the concentrations of vancomycin and gentamicin in the serum and CSF during 100 ventriculoperitoneal shunt surgeries at the time of shunt manipulation. Design: Descriptive, prospective, observational study with a 27- to 76-month postoperative follow-up period range. Setting: University hospital. Patients: Eighty-three hydrocephalic patients ranging from premature to adult ages. Interventions: Intraoperatively, children received intravenous vancomycin 15 mg/kg/dose and gentamicin 2.5 mg/kg/dose; adults received vancomycin 1 g/dose and gentamicin 1.5 mg/kg/dose. Antibiotics were continued for 24 hours postoperatively, with dosage and schedule adjusted for age. Antibiotic serum and CSF concentrations were sampled one hour after infusion, and measured via fluorescence polarization immunoassay. Meticulous surgical infection control measures were followed. Main Outcome Measures: Correlation of intraoperative serum and CSF antibiotic concentrations with postoperative infection rate. Results: Intraoperative vancomycin serum concentrations ranged from 10.8 to 53.8 μg/mL (28.0 ± 9.5 μg/mL, mean ± SD). Intraoperative gentamicin serum concentrations ranged from 3.9 to 9.4 μg/mL (4.8 ± 2.0 μg/mL). In all surgeries, intraoperative CSF vancomycin and gentamicin concentrations were low (vancomycin <5 μg/mL, gentamicin <2 μg/mL). The infection rate among surgeries was 2.0%, and the infection rate among patients was 2.4%. Two shunt infections occurred, one with Candida albicans and one with Citrobacter freundii. Conclusions: Serum concentrations of vancomycin and gentamicin were above the minimum inhibitory concentrations for likely pathogens in 84% and 74% of surgeries, respectively. Intraoperative bacteriostatic and bactericidal CSF antibiotic concentrations may not be necessary to achieve a low postoperative shunt infection rate. Larger confirmatory studies are needed.

Patterns in neurosurgical adverse events: cerebrospinal fluid shunt surgery

2012 ◽  
Vol 33 (5) ◽  
pp. E13 ◽  
Author(s):  
Judith M. Wong ◽  
John E. Ziewacz ◽  
Allen L. Ho ◽  
Jaykar R. Panchmatia ◽  
Angela M. Bader ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Adverse Events ◽  
Ventriculoperitoneal Shunt ◽  
Shunt Infection ◽  
Current Evidence ◽  
Csf Shunt ◽  
Complication Rates ◽  
Cerebrospinal Fluid Shunt ◽  
Shunt Surgery ◽  
Programmable Valves

Object As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in CSF shunt surgery concerning the frequency of adverse events in practice, their patterns, and the state of knowledge regarding methods for their reduction. This review may also inform future and ongoing efforts for the advancement of neurosurgical quality. Methods The authors performed a PubMed search using search terms “cerebral shunt,” “cerebrospinal fluid shunt,” “CSF shunt,” “ventriculoperitoneal shunt,” “cerebral shunt AND complications,” “cerebrospinal fluid shunt AND complications,” “CSF shunt AND complications,” and “ventriculoperitoneal shunt AND complications.” Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the adverse events reported. Results In this review of the neurosurgery literature, the reported rate of mechanical malfunction ranged from 8% to 64%. The use of programmable valves has increased but remains of unproven benefit even in randomized trials. Infection was the second most common complication, with the rate ranging from 3% to 12% of shunt operations. A meta-analysis that included 17 randomized controlled trials of perioperative antibiotic prophylaxis demonstrated a decrease in shunt infection by half (OR 0.51, 95% CI 0.36–0.73). Similarly, use of detailed protocols including perioperative antibiotics, skin preparation, and limitation of OR personnel and operative time, among other steps, were shown in uncontrolled studies to decrease shunt infection by more than half. Other adverse events included intraabdominal complications, with a reported incidence of 1% to 24%, intracerebral hemorrhage, reported to occur in 4% of cases, and perioperative epilepsy, with a reported association with shunt procedures ranging from 20% to 32%. Potential management strategies are reported but are largely without formal evaluation. Conclusions Surgery for CSF shunt placement or revision is associated with a high complication risk due primarily to mechanical issues and infection. Concerted efforts aimed at large-scale monitoring of neurosurgical complications and consistent quality improvement within these highlighted realms may significantly improve patient outcomes.

scholarly journals Shunt scissors: technical note

2018 ◽  
Vol 129 (5) ◽  
pp. 1200-1202
Author(s):  
Ralph G. Dacey ◽  
Oliver E. Flouty ◽  
M. Sean Grady ◽  
Matthew A. Howard ◽  
Marc R. Mayberg
Keyword(s):  
Ventriculoperitoneal Shunt ◽  
Technical Note ◽  
Shunt Surgery ◽  
Blunt Dissection ◽  
Technical Advance ◽  
Shunt Valve ◽  
New Device ◽  
Sharp Dissection ◽  
Dissection Technique ◽  
Subgaleal Space

OBJECTIVEWhen performing ventriculoperitoneal shunt surgery it is necessary to create a subgaleal pocket that is of sufficient size to accommodate a shunt valve. In most cases the valve is placed over the posterior skull where the galea begins to transition to suboccipital neck fascia. Dense fibrous attachments in this region of the skull make it technically awkward to develop the subgaleal valve pocket using standard scissors and a blunt dissection technique. In this report the authors describe a new device that enables surgeons to create the shunt valve pocket by using a simple semi-sharp dissection technique.METHODSThe authors analyzed the deficiencies of the standard valve pocket dissection technique and designed shunt scissors that address the identified shortcomings. These new scissors allow the surgeon to sharply dissect the subgaleal space by using an efficient hand-closing maneuver.RESULTSStandard surgical scissors were modified to create shunt scissors that were tested on the benchtop and used in the operating room. In all cases the shunt scissors proved easy to use and allowed the efficient and reliable creation of a subgaleal valve pocket in a technically pleasing manner.CONCLUSIONSShunt scissors represent an incremental technical advance in the field of neurosurgical shunt operations.

scholarly journals In situ clearance of a proximal shunt malfunction in a child with hydrocephalus post cerebral arteriovenous malformation rupture noted intraoperatively

2020 ◽  
Vol 11 ◽  
pp. 116
Author(s):  
Zachary Porter ◽  
George Yang ◽  
Shawn Vuong ◽  
Baher Hanna ◽  
Joseph Madsen ◽  
...  
Keyword(s):  
Arteriovenous Malformation ◽  
Ventriculoperitoneal Shunt ◽  
External Ventricular Drain ◽  
Cerebral Arteriovenous Malformation ◽  
Csf Shunt ◽  
Ventricular Catheter ◽  
Csf Flow ◽  
Shunt System ◽  
Shunt Valve

Background: Hydrocephalus shunt malfunctions remain treated with surgical intervention only. Despite efforts at identifying or preventing CSF shunt obstruction, no evidence currently exists to restore CSF flow following proximal occlusion, non-invasively. Case Description: We present direct intraoperative evidence in the case of a 5-year-old male who developed hydrocephalus subsequent to hemorrhagic presentation post cerebral arteriovenous malformation rupture. After weeks of externalized CSF diversion for clearance of CSF red blood cells, he was taken to the operating room for removal of the external ventricular drain and placement of a ventriculoperitoneal shunt for hydrocephalus. At conclusion of placing his ventriculoperitoneal shunt with ReFlow flusher assist device, his shunt valve reservoir was noted to not refill. Following manual depression of the ReFlow flusher, we identified clearance of debris from the obstructed ventricular catheter allowing reestablished CSF flow through the shunt system under live intraoperative ultrasonography. Subsequently, there was return of brisk refill to the shunt valve reservoir. Conclusion: Observations here demonstrate a potentially useful technical strategy toward clearance of proximal shunt obstructions, in situ.

Spontaneous bowel perforation after ventriculoperitoneal shunt surgery: case report and a review of 45 cases

2000 ◽  
Vol 54 (5) ◽  
pp. 388-396 ◽  
Author(s):  
Satish Sathyanarayana ◽  
Esther L Wylen ◽  
Mustafa K Baskaya ◽  
Anil Nanda
Keyword(s):  
Case Report ◽  
Ventriculoperitoneal Shunt ◽  
Bowel Perforation ◽  
Shunt Surgery

Endoscopic Third Ventriculostomy in Infants Less than One Year of Age: A Short Series of 14 Cases

2021 ◽  
Vol 56 (2) ◽  
pp. 105-109
Author(s):  
Sarita Chowdhary ◽  
Shyamendra Pratap Sharma ◽  
Pranaya Panigrahi ◽  
Manoj Kumar Yadav ◽  
Shiv Prasad Sharma
Keyword(s):  
Endoscopic Third Ventriculostomy ◽  
Obstructive Hydrocephalus ◽  
Aqueductal Stenosis ◽  
Csf Shunt ◽  
Third Ventriculostomy ◽  
Occipital Encephalocele ◽  
Shunt Implantation ◽  
Permanent Morbidity ◽  
One Year

<b><i>Background:</i></b> Endoscopic third ventriculostomy (ETV) is currently considered as an alternative to cerebrospinal fluid (CSF) shunt systems in the treatment of obstructive hydrocephalus. This procedure allows the CSF to drain in the basal cisterns and reabsorbed by arachnoid granulations, and avoiding implantation of exogenous material. <b><i>Aims and Objectives:</i></b> The purpose of this study was to assess the success rate of ETV in infants less than 1 year of age with congenital noncommunicating hydrocephalus. <b><i>Material and Methods:</i></b> This study was a 2-year prospective study from August 2017 to July 2019. ETVs were performed in 14 patients younger than 1 year with diagnosis of noncommunicating hydrocephalous. A failure was defined as the need for shunt implantation after ETV. Phase-contrast MRI of the brain was done after 6 months to see patency of ETV fenestration and CSF flow through ventriculostomy. <b><i>Results:</i></b> ETV was tried in 18 patients and successfully performed in 14 patients. Out of the 14 patients, shunt implantation after ETV was performed in 3 patients (failed ETV). In the successful cases, etiology was idiopathic aqueductal stenosis in 8, shunt complications in 2, and 1 case was a follow-up case of occipital encephalocele; the mean age was 7.7 months (range 3–12). In the 3 failed cases, etiology was aqueductal stenosis, mean age was 7.6 months (range 3–11). In all ETVs, failed patients MPVP shunting was done. Follow-up of nonshunted patients was done from 6 to 24 months (mean 15 months). There was no mortality or permanent morbidity noted following ETV. <b><i>Conclusion:</i></b> ETV is a good surgical procedure for less than 1-year-old children.

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