Level of IL-6 in cerebrospinal fluid is a preoperative predictor of short - term outcome in acquired hydrocephalus

Background: Acquired hydrocephalus (AH) is a common complication in patients with severe brain injury. Brain tissue injury has been proposed to induce a neuroinflammatory reaction reflected by cytokines release, particularly interleukin-6 (IL-6), which associates with early brain damage. The present study measured IL-6 in the cerebrospinal fluid (CSF) of AH patients and determined its relationship to functional outcome following shunt operation.Methods: The study included a total of 32 patients with a shunt operation due to hydrocephalus. CSF samples from 26 AH subjects and 6 iNPH patients were collected via lumbar puncture before surgery. IL-6 level was measured using the micro ELISA immunoassay method. AH subjects were dichotomized into good versus poor outcomes based on modified Rankin Scale (mRS) at 3 months after shunting.Results: CSF analysis demonstrated that IL-6 was significantly elevated in the CSF of the AH group compared to controls (p = 0.023). Within the AH group, eighteen (69.2%) had a good outcome while eight (30.8%) patients had a poor outcome. Mean IL-6 level in the good outcome group was approximately four-times higher than the poor outcome group (p = 0.004). Glasgow Coma Scale (GCS) on admission was significantly different between the two groups (p = 0.014). IL-6 level and admission GCS were significantly correlated with improvement of mRS score (r = 0.473, p = 0.015 and r = 0.691, p＜0.0001, respectively). Receiver operating characteristic curve analysis showed that both factors can accurately differentiate between patients with good versus poor functional outcome (AUC = 0.861, p = 0.0039 and AUC = 0.823, p = 0.0098, respectively). Conclusions: The CSF level of IL-6 is elevated in AH patients and higher levels correlate with improvement of post-shunt functional outcome. Therefore, IL-6 CSF level might serve as a complementary surrogate parameter for operative indication. A possible IL-6 threshold in clinical routine might be a 6.98-pg/ml cutoff value to rule out unresponsive and poor outcome AH patients that are under the 6.98-pg/ml threshold.

EARLY OUTCOME ANALYSIS OF NEURAL TUBE DEFECTS PRESENTING IN NEONATAL PERIOD: OUR EXPERIENCE

Background: Neural tube defects (NTDs) are congenital malformation resulting from failure of complete or partial closure of the neural tube in developing embryo. Aims and Objectives: The aim of this study is to present our experience, management and early outcomes (one month post-operatively) of neural tube defects presenting in neonatal period at our high volume tertiary care teaching Institutions. Materials and methods: This retrospective cohort study was conducted over a period of 10 years from January 2007 to December 2016. Medical records of neonates treated for neural tube defects were recorded in a pre-designed Performa. Results: A total of 286 patients with clinically diagnosed neural tube defects presenting in the neonatal period were studied. Male: female ratio was 1.11. The mean birth weight was 2350g. History of peri-conceptional use of folic acid was found in 15 (5.24%) mothers. One hundred seventeen (40.90%) of the patients had multiple system involvement. Most common was orthopedic deformities. Associated hydrocephalus was appreciated in 259 (90.56%) patients. Meningomyelocele was the most common anomaly seen in 239 (83.57%), 24 (8.39%) as meningocele and 23 (8.04%) were diagnosed as having Encephalocele. Surgery with decapping and repair was performed in 277 (96.85%) of the patients. Ventriculoperitoneal (VP) shunt operation before repair of meningomyelocele was performed in 9 (3.15%) patients, while in 19 (6.64%) patients, VP shunt operation was performed after the repair of NTD's in the early (one month) postoperative period. Clinical sepsis developed in the postoperative period in twenty one (7.58%) out of 277 patients, for which antibiotics were stepped up. Thirteen patients (4.69%) died postoperatively due to sepsis and associated anomalies. Conclusions: We present our retrospective report on neural tube defects from Indian subcontinent with accurate baseline data. Meningomyelocele was the most common type of NTD's. We recommend that folic acid supplementation should begin before marriage to raise its serum levels before the conception. Antenatal care especially antenatal ultrasonography must be contemplated as early as possible in early detection of NTDs.

Normalized Power Variance: A New Field Orthogonal to Power in EEG Analysis

To date, electroencephalogram (EEG) has been used in the diagnosis of epilepsy, dementia, and disturbance of consciousness via the inspection of EEG waves. In addition, EEG power analysis combined with a source estimation method like exact-low-resolution-brain-electromagnetic-tomography (eLORETA), which calculates the power of cortical electrical activity from EEG data, has been widely used to investigate cortical electrical activity in both healthy individuals and neuropsychiatric patients. However, the recently developed field of mathematics “information geometry” indicates that EEG has another dimension orthogonal to power dimension — that of normalized power variance (NPV). By also introducing the idea of information geometry, a significantly faster convergent estimator of NPV was obtained. In this study, we applied this NPV analysis of eLORETA to idiopathic normal pressure hydrocephalus (iNPH) patients prior to a cerebrospinal fluid (CSF) shunt operation, where traditional power analysis could not detect any difference associated with CSF shunt operation outcome. NPV analysis detected significantly higher NPV values at the high convexity area in the beta frequency band between 17 shunt responders and 19 non-responders. Our findings demonstrated that EEG has another dimension — that of NPV, which contains a great deal of information about cortical electrical activity that can be useful in clinical practice.

Shunt Infection in Adults: A Retrospective Study of 1324 Cases

Background: Shunt infection (SI) is a serious major complication in the management of hydrocephalus after cerebral fluid shunts. Here we study retrospectively hydrocephalus shunting to evaluate the incidence of SI, including the risk factors and types of infection.Meterial and Methods: 1556 patients (age≥18years) who had undergone shunt surgery from January 2013 to December 2019 at our center were included(6-78 months follow-up period). 1324 cases of them were confirmed as effective cases. Infection rate and risk factors were investigated.Results: We found 79 (6.0%) cases (58 men and 21 women) with SI, of which 72 were ventriculo-peritoneal (VP) shunt and 7 were lumbo-peritoneal (LP) shunt. Risk factors include male gender (p=0.04), patients with a history of intracranial infection (p<0.001) and patients suffered an infection when shunt surgery performed (p=0.008). Surgery type (p=0.80), Glasgow Coma Score (GCS) before shunt procedure (p=0.57) and history of hypertension (p=0.16), diabetes (p=0.44) or cerebral infarction (p=0.29) were not risk factors of SI. Brain or spine surgery performed within 2 years prior to shunt procedure increased rate of SI (p=0.015, SI rate: 7.4%), but not when performed after shunt procedure (p=0.42). Idiopathic hydrocephalus and hydrocephalus caused by trauma, hemorrhage, tumor and other factors showed no significant correlation with SI. Of all SI, 48 (60.8%) and 62 (78.5%) cases were present within 1 and 2 months after shunt surgery, respectively. Only 2.5% (2/79) of SI were found after 1 year since shunt placement. Pathogens were found in 46 cases, and Gram positive cocci were accounted for 50.0% (23/46). Conclusions: Our study suggests that male, history of intracranial infection, patients’ infection status when shunt surgery performed and history of brain or spine surgery performed within 2 years are risk factors of SI. Infections are more likely to present within the first 2 months after shunt placement, only 2.5% shunt infections were found after more than 1 year form shunt operation.

Ventriculoperitoneal shunt failure in pediatric patients: an analysis of a national hospitalization database in Thailand

OBJECTIVE Shunt failure is common among patients undergoing ventriculoperitoneal shunting for treatment of hydrocephalus. The present study examined long-term shunt failure and associated risk factors in pediatric patients by using a national hospitalization database of Thailand. METHODS Patients 17 years or younger who had been admitted to 71 public hospitals in 2012–2017 for first-time ventriculoperitoneal shunting for diseases with known etiology and discharged alive were followed through 2019 to ascertain shunt failure. Shunt survivals were calculated using Kaplan-Meier estimates and time to failure was analyzed to identify risk factors for the first failure by using Cox proportional hazards regression. Differences in risks of subsequent failures with respect to place in the order of failures (i.e., first, second, third) were determined using a cumulative hazard function. RESULTS Over a median follow-up of 29.9 months, shunt failure occurred in 33.7% of 2072 patients (median age 8.8 months), with a higher proportion in patients < 1 year than in patients 1–17 years (37.8% vs 28.9%, p < 0.001), and ranged from 26.1% of those having posttraumatic hydrocephalus to 35.9% of those having infectious diseases. The shunt failure rates at 3, 6, and 12 months were 11.5%, 19.0%, and 25.2%, respectively. Patients < 1 year had a higher risk of the first failure than patients 1–17 years (hazard ratio 1.45, 95% CI 1.20–1.76). Among those with shunt failure, 35.8% had multiple failures and 52.9% failed within 180 days after the index shunting. The cumulative hazard of subsequent failure was consistently higher than that of an earlier failure regardless of age and etiology, and the cumulative hazard of the second failure in the patients with 180-day failure was higher than that in the patients in whom shunts failed beyond 180 days. CONCLUSIONS Shunt failure occurred more frequently in younger pediatric patients. Much attention should be placed on the initial shunt operation so as to mitigate the failure risk. Close follow-up was crucial once patients had developed the failure, because the risk of subsequent failure was more likely than an earlier one among those with multiple failures.

Fetal Cardiac Parameters for Predicting Postnatal Operation Type of Fetuses With Tetralogy of Fallot

Background: To assess fetal cardiac parameters predictive of postnatal operation type in fetuses with tetralogy of Fallot (TOF). Methods: Echocardiographic data obtained in the second and third trimesters were retrospectively reviewed for fetuses diagnosed with TOF between 2014 and 2018 at Asan Medical Center. The following fetal cardiac parameters were analyzed: 1) pulmonary valve annulus (PVA) z-score, 2) right pulmonary artery (RPA) z-score, 3) aortic valve annulus (AVA) z-score, 4) pulmonary valve peak systolic velocity (PV-PSV), 5) PVA/AVA ratio, and 6) RPA/descending aorta (DAo) ratio. These cardiac parameters were compared between a primary corrective surgery group and a palliative shunt operation followed by complete repair group. Results: A total of 100 fetuses with TOF were included. Only one neonatal death occurred. Ninety patients underwent primary corrective surgery and 10 neonates underwent a multistage surgery. The PVA z-score, RPA z-score, and RPA/DAo ratio measured in the second trimester and the PVA z-score, RPA z-score, and PVA/AVA raio measured in the third trimester were significantly lower in the multistage surgery group, while the PV-PSV as measured in both trimesters were significantly higher in the multistage surgery group. Conclusion: Fetal cardiac parameters are useful for predicting the operation type necessary for neonates with TOF.

The Hemodynamics of Patent Ductus Arteriosus in Patients after Central Shunt Operation

A central shunt (CS) was an important surgery of systemic-to-pulmonary shunt (SPS) for the treatment of complex congenital heart diseases with decreased pulmonary blood flow (CCHDs-DPBF). There was no clear conclusion on how to deal with unclosed patent ductus arteriosus (PDA) during CS surgery. This study expanded the knowledge base on PDA by exploring the influence of the closing process of the PDA on the hemodynamic parameters for the CS model. The initial three-dimensional (3D) geometry was reconstructed based on the patient’s computed tomography (CT) data. Then, a CS configuration with three typical pulmonary artery (PA) dysplasia structures and different sizes of PDA was established. The three-element windkessel (3WK) multiscale coupling model was used to define boundary conditions for transient simulation through computational fluid dynamics (CFD). The results showed that the larger size of PDA led to a greater systemic-to-pulmonary shunt ratio ( Q S / A ), and the flow ratio of the left pulmonary artery (LPA) to right pulmonary artery (RPA) ( Q L / R ) was more close to 1, while both the proportion of high wall shear stress (WSS) areas and power loss decreased. The case of PDA nonclosure demonstrates that the aortic oxygen saturation (Sao2) increased, while the systemic oxygen delivery (Do2) decreased. In general, for the CS model with three typical PA dysplasia, the changing trends of hemodynamic parameters during the spontaneous closing process of PDA were roughly identical, and nonclosure of PDA had a series of hemodynamic advantages, but a larger PDA may cause excessive PA perfusion and was not conducive to reducing cyanosis symptoms.

Shunt occlusion in neonates with congenital heart disease undergoing systemic-to-pulmonary shunt surgery in the Neonatal Intensive Care Unit, Maharaj Nakorn Chiang Mai Hospital

Objectives To study occlusion of shunts and related factors in neonates after systemic-to-pulmonary shunt surgery. Methods This retrospective descriptive study reviewed the medical records of neonates in the Neonatal Intensive Care Unit who underwent a systemic-to-pulmonary shunt operation at Maharaj Nakorn Chiang Mai Hospital between January 1, 2011 and December 31, 2016. Patient characteristics and operative data were collected. Demographic data and incidence of shunt occlusion were analyzed using descriptive statistics. Factors associated with shunt occlusion were identified using Fisher’s exact test and the Mann-Whitney U test. Results Seventy-five newborns were enrolled in the study, of whom 39 (52.0%) were female. The average birth weight was 2,711.1 grams, and the average gestational age was 37.6 weeks. The number of newborns with TOF or TOF/IVS was equal to those with PA/IVS (34.7%). Sixty neonates (80%) underwent Modified Blalock Taussig shunt surgery, most (57.3%) with a 3.5 Fr. diameter shunt. The average weight at surgery was 2,898.9 grams, and the average age at surgery was 17.6 days. Anticoagulant and anti-platelet medication was used with almost all the neonates following surgery (96.0% and 93.3%, respectively). The incidence of shunt occlusion was 22.7% (17 neonates). Complete occlusion was found in 11 neonates. In-hospital shunt occlusion occurred in 10 neonates as well as in 7 neonates after discharge from the hospital. The overall mortality rate was 14.7%. Congenital heart disease diagnosis and gestational age were significantly associated with shunt occlusion (p = 0.02 and p = 0.01, respectively). Conclusion The study results can be used to provide develop guidelines for treatment of neonates with complex heart disease and low gestational age as well as nursing care guidelines for the prevention of blockage of the shunt in neonates undergoing a systemic-to-pulmonary shunt operation due to hospitalization in a hospital.

Shunt Infection

The improvement in the management of hydrocephalus comes from the following: early diagnosis, radiological investigation, better knowledge of mechanisms, quality of material, surgical technique of implantation, less shunt complications (e.g.infections) and alternatives to shunt (e.g. Neuroendoscopy). However, shunt infection does not improve in the last decades, ranging from 3 to 12%. Shunt infection can be classified in: would infection, CSF infection, infected shunt system, abdominal complications (infection). The main agent is Staphylococcus, causing 67%-85% of problems, mainly due to colonization of shunt by skin flora. The majority of cases occur during the first 2 months (85%), late infection is rare. Risk factors to infection are the following: the cause of hydrocephalus, clinical condition and the age of children, operation time of the day, the duration of the shunt operation, the number of persons in OR, shunt material (Antibiotic catheter), presence of previously shunt system, postoperative CSF leak, perioperative antibiotics and economic level of Medical Center. Recommended management of shunt infection: removal of the shunt, insertion of an external drainage (EVD) (always in operation room), change EVD after 15 days, intravenous antibiotics, replacement of ventriculoperitoneal shunt after 3 sterile cultures. The most feared complications of Shunt infection are mortality, morbidity and cost. In conclusion: SHUNT INFECTION IS NOT A FATALITY