Removal of the Retained Ventricular Catheter Using the Endoscopic Monopolar Instrument

Background. Ventriculoperitoneal shunt (VPS) remains the main treatment for hydrocephalus. However, VPS revision surgery is very common. Here, we present a case in which the retained ventricular catheter was removed using the endoscopic monopolar instrument. Methods. We report a case of a 28-year-old female who presented with VPS obstruction. She had two previous shunt revision surgeries due to shunt obstruction. Eleven years after the last one, she presented an abdominal pseudocyst that indicated a total system removal. During VPS revision surgery, a retained ventricular catheter was observed. The endoscopic monopolar instrument was introduced into the retained catheter under direct view. Coagulations in a back-and-forth movement were applied to release inner catheter adhesions. After these steps, the catheter was removed, and a new one was placed through the same route. Results. The catheter was removed without complications, confirmed by the postoperative cranial computed tomography. The patient remained asymptomatic. Conclusion. The described technique was effective and avoided ventricular bleeding. Further studies are necessary to validate this method.

The role of shuntography in diagnosis of mechanic complications after implantation of ventriculoperitoneal shunts in patients with idiopathic normal pressure hydrocephalus: a retrospective clinical evaluation

Background Mechanical obstruction of ventriculoperitoneal shunt (VPS) during the first year after shunt implantation is a common complication and is widely described in the literature. In this paper, we evaluated the suitability of the shuntography for the diagnosis of mechanical complications of the VPS in patients with idiopathic normal pressure hydrocephalus (iNPH). Methods We retrospectively identified 49 patients with pathologic shuntography over of a period of 20 years in our hospital. The percentage of procedure-associated complications was determined. Results Ninety-eight percent (n = 48) of the patients who underwent shuntography showed clinical and radiographic signs of underdrainage prior to examination. Shuntography revealed mechanical complications of the VP shunt in 37% (n = 18) as a cause of clinical deterioration and following revision operation. During shuntography, mechanical obstruction was discovered in 78% (n = 14) and disconnection of shunt components in 22% (n = 4). In the obstruction group, in 50% (n = 7) the closure was detected in the ventricular catheter, in 29% (n = 4) in the distal catheter of the VPS, and in 21% (n = 3) in both sides of the VPS. In the case of an inconspicuous shuntography (63%, n = 31), the patients received symptomatic therapy (32%, n = 10) or re-adjustment of the valve setting (68%, n = 21). Fifty-seven percent of the patients who underwent surgical treatment improved clinically by at least one point according to the Kiefer score. Conclusion Shuntography can produce valuable clinical information uncovering mechanic complications after implantation VPS in patients with idiopathic normal-pressure hydrocephalus. Patients with mechanical complications of their VPS needed revision surgery and showed clinical benefit after treatment.

Anterior versus posterior entry site for ventriculoperitoneal shunt insertion: a randomized controlled trial by the Hydrocephalus Clinical Research Network

OBJECTIVE The primary objective of this trial was to determine if shunt entry site affects the risk of shunt failure. METHODS The authors performed a parallel-design randomized controlled trial with an equal allocation of patients who received shunt placement via the anterior entry site and patients who received shunt placement via the posterior entry site. All patients were children with symptoms or signs of hydrocephalus and ventriculomegaly. Patients were ineligible if they had a prior history of shunt insertion. Patients received a ventriculoperitoneal shunt after randomization; randomization was stratified by surgeon. The primary outcome was shunt failure. The planned minimum follow-up was 18 months. The trial was designed to achieve high power to detect a 10% or greater absolute difference in the shunt failure rate at 1 year. An independent, blinded adjudication committee determined eligibility and the primary outcome. The study was conducted by the Hydrocephalus Clinical Research Network. RESULTS The study randomized 467 pediatric patients at 14 tertiary care pediatric hospitals in North America from April 2015 to January 2019. The adjudication committee, blinded to intervention, excluded 7 patients in each group for not meeting the study inclusion criteria. For the primary analysis, there were 229 patients in the posterior group and 224 patients in the anterior group. The median patient age was 1.3 months, and the most common etiologies of hydrocephalus were postintraventricular hemorrhage secondary to prematurity (32.7%), myelomeningocele (16.8%), and aqueductal stenosis (10.8%). There was no significant difference in the time to shunt failure between the entry sites (log-rank test, stratified by age < 6 months and ≥ 6 months; p = 0.061). The hazard ratio (HR) of a posterior shunt relative to an anterior shunt was calculated using a univariable Cox regression model and was nonsignificant (HR 1.35, 95% CI, 0.98–1.85; p = 0.062). No significant difference was found between entry sites for the surgery duration, number of ventricular catheter passes, ventricular catheter location, and hospital length of stay. There were no significant differences between entry sites for intraoperative complications, postoperative CSF leaks, pseudomeningoceles, shunt infections, skull fractures, postoperative seizures, new-onset epilepsy, or intracranial hemorrhages. CONCLUSIONS This randomized controlled trial comparing the anterior and posterior shunt entry sites has demonstrated no significant difference in the time to shunt failure. Anterior and posterior entry site surgeries were found to have similar outcomes and similar complication rates.

P.166 Assessment of External Ventricular Catheter Associated Infections at the Ottawa Hospital: Literature Review and Quality Improvement Initiative

Background: External ventricular drains are a lifesaving intervention in the management of acute hydrocephalus. EVD associated infections vary significantly, and expert panels recommend reviewing institutional policies if infection rates exceed 10%. The audit aims to identify the infection rate at our institution, whereas the literature review aims to synthesize a new institutional EVD best practice guideline. Methods: An audit of EVD catheters inserted in the time period between 07/01/2019 and 10/25/2020 was conducted. Statistical analysis to calculate absolute incidence, infections per 1000 days of catheter use. A literature review to identify best practices for the insertion and management of EVDs was conducted. Results: 75 patients required a total of 105 EVD catheters. There were 16 (15.3%) EVD related infections, equating to 14.3 infections per 1000 days. Fifty percent of patients developed an EVD related infection within 9 days of insertion. Most infections were induced by skin flora (87.5%). A comprehensive step-by-step EVD insertion and management protocol was developed aiming to reduce the risk of infection. Conclusions: The incidence of EVD associated infections at the Ottawa Hospital is significantly higher than acceptable rates as suggested by expert panels. A new evidence-based best practice guidelines should be implemented. A follow-up audit is necessary.

Shuntoscope-Guided Versus Free Hand Technique for Ventricular Catheter Placement: A Prospective Comparative Study of Intra-Ventricular Catheter Tip Position and Complication Rate

Background: The position of the ventricular catheter (VC) is essential for a proper function of cerebrospinal fluid diversion system. A shuntoscope-guided (SG) method might be helpful in reducing complications. Objective: The purpose of this study is to compare the accuracy of catheter placement and the complication and revision rates between SG and free hand (FH) techniques. Methods: A prospective study of patients who underwent VC placement between September 2018 and March 2021. Accuracy of catheter placement was graded on postoperative imaging using three-point Hayhurst grading system. Complication and revision rates were documented and compared between both groups with an average follow up period of 19.56 months. Results: Fifty-five patients were included. SG technique was used in 29 patients (mean age was 6.3 years, 1.4 –27.7 years, 48.1% females), and FH technique was used in 26 patients (mean age was 28.6 years, 1.0 – 79.5 years, 73.1% female). The success rate for the optimal placement of the VC with a grade I on the Hayhurst scale was significantly higher in the SG group (93.1%) than in the FH group (67%), P = 0.031. The revision rate was higher in the FH group with 31.8% vs. 20.7% of in the SG group, P = 0.396. Conclusion: VC placement using the SG technique is a safe and effective procedure, which enabled a significantly higher success rate and lower revision and complication rate. Accordingly, we recommend using the SG technique specially in patients with morbid anatomy.

Local 3-Dimensional Printing of a Calvarium-Anchored Ventricular Catheter Occlusion Device

ABSTRACT Three-dimensional (3D)-printed objects have been incorporated into many surgical specialties for various purposes. These devices can be customized and used as implants or surgical instruments. This study describes the use of a 3D-printed device that eliminates the need for a surgical assistant to occlude and retain the intracranial catheter during ventriculoperitoneal shunt creation and revision. After we identified design considerations and solutions, we modeled the device dimensions using computer-aided design software. Prototypes were 3D printed using stereolithography. Iterative design improvements were tested on cadaveric cranial samples. A final design was established, prepared by the in-hospital sterile processing department, and deployed successfully for clinical use. The design process for 3D-printed surgical instruments can produce straightforward idea-to-prototype pipelines. Because 3D-printed devices are easily duplicated and modified, small adjustments and new models can be developed, printed, and tested in a short time span.

P13.22 Menglia: an innovative approach to liquid biopsies in glioma patients

BACKGROUND Gliomas are the second most frequent primary brain tumor. Since 2016 gliomas are classified according to histological, and molecular features such as IDH status and 1p19q codeletion. Recently oncological research has focused on liquid biopsies to reduce the need for invasive diagnostic tests. Cerebrospinal fluid (CSF) is the principal source of brain tumor biomarkers. Modern technologies currently allow us to analyze proteomic and metabolomic tumor profiles, in order to find new biomarkers without being constrained by a priori hypothesis. Several data from the literature also suggests that inflammatory cells and cytokines in tumors contribute to tumor growth, progression and immunosuppression. The possibility of simultaneously testing different inflammatory molecules on the biological fluids could lead to the identification of new biological markers with prognostic and predictive value for treatment response. STUDY OBJECTIVES - Identification of protein and/or lipid biomarkers specific to the glioma subgroup among those under analysis. - Identification of tumor group- and subgroup-specific CSF and/or serum inflammatory biomarkers among those tested. - Correlation of biomarkers with Progression Free Survival (PFS), Overall Survival (OS). ELIGIBILITY CRITERIA - Patients with a radiological suspected diagnosis of glioma eligible for surgery. - Age ≥ 18 years. - Availability of histological samples, CSF, blood and urine. - Patients with unconfirmed histological diagnosis of glioma will be excluded. - Patients who have never received any systemic or local treatment for CNS diseases. STUDY DESIGN This is a prospective monocentric study involving mass spectrometry analysis for characterization of proteins and metabolites and ELISA analysis for the characterization of different cytokines in parallel anonymized biological samples consisting of tumor tissue, CSF, blood and urine from glioma patients, divided into three different molecular subtypes: 1p19q codelet/IDH mutated, 1p19q non-codelet/IDH mutated and 1p19q non-codelet/IDH wt. Biological samples will be taken at surgery, at 24–48 h after surgery and every 3 months up to 1 year. The control group will include patients with subarachnoid hemorrhage or hydrocephalus, either undergoing external ventricular shunting or undergoing ventricular catheter placement/revision surgery. STUDY ANALYSIS Data interpretation will be based on a statistical analysis of the data, applying tools such as Principal Component Analysis (PCA) Weighted Correlation Network Analysis (WGNCA), Multiple Venn Diagram, T-Test, ANOVA, Clustering and Gene Ontology Enrichment, non-parametric Mann-Whitney test. For the assessment of clinical outcome, survival curves will be compared between different groups of patients who share a similar protein/metabolomic/inflammatory profile.

Potential Risk Factors for Ventriculoperitoneal Shunt Implantation in Paediatric Patients with Posthemorrhagic Hydrocephalus of Prematurity Treated with Subcutaneous Reservoir: An Institutional Experience

Background Posthemorrhagic hydrocephalus of prematurity (PHHP) is a result of intraventricular hemorrhage (IVH). IVH occurs in 6 to 23% of the preterms in countries with advanced medical health care. Most of these patients will eventually require the use of ventriculoperitoneal shunt (VPS). The purpose of this study is to assess the risk factors of VPS implantation in patients with PHHP who have been treated with ventricular catheter with subcutaneous reservoir (VCSR). Methods The retrospective study was conducted evaluating 35 premature patients who suffered from severe IVH. Their mean gestational age was 28 weeks. The assessment included antenatal factors such as gestational age, birth weight, and intrauterine and perinatal infection. Postparturient period factors such as the IVH grade, time between diagnosis, and VCSR implantation and body weight on VCSR implantation were also considered in the study. Postprocedural complications, such as bacterial cerebrospinal fluid (CSF) infection, sepsis, and skin lesions, were evaluated. Data were calculated with R program, version 4.04. Results From among 35 evaluated patients, 23 (65.71%) required a VPS. Median of birth weight was 1,190 g. Infections were observed in 11 (31.43%) cases. Mean time between IVH diagnosis and VCSR implantation was 2.6 weeks. Postprocedural complications occurred in 19 (54.29%) patients. None of the evaluated factors has proven its statistical significance (p > 0.05) for being a potential risk factor for VPS implantation. Conclusion External factors seem to not affect the necessity of VPS implantation in patients after the severe IVH. Ostensibly, there seems to be no difference between the grades III and the IV of Papile's IVH scale regarding VPS implantation necessity.