Comparison of Lumbarperitoneal Shunt with the Stereotactic Ventriculoperitoneal Shunt for the Treatment of Refractory Idiopathic Intracranial Hypertension：A Case Report and Literature Review

BackgroundIdiopathic intracranial hypertension (IIH) or pseudotumor cerebri (PTC), is a disorder of young obese females and characterized by headache, papilledema with raised intracranial pressure in the absence of known pathological cause. Due to the uncertainty of etiology, it may lead to misdiagnosis and poor outcome. IIH is typically treated with shunts (lumbarperitoneal and ventriculoperitoneal shunting), but shunts are prone to malfunction and infection, resulting in many patients experiencing recurrent headaches post-treatment. Case presentationWe report a case of 41 years old obese female (BMI:30.9) with IIH who exhibited a history of hypertension (BP:150/100mmHg) and documented elevated intracranial pressure (OP:450mm H2O). After the failure of several medical treatments, the patient was offered LPS due to vision loss and headache, but postoperative symptoms (intermittent headache-mainly whole craniocerebral prickling pain accompanied by neck and shoulder pain) did not significantly relieve lasting for 11 years. Therefore, we considered the blockage of the primary shunt tube in the patient, and the patient with a small ventricle leads to some difficulty in ventricle puncture, then we had to treated with the stereotactic VPS（VPS）for her exacerbation symptoms. More surprisingly, the hypertension was within the normal range (<115/80mmHg) after the surgery (without antihypertensive medication).Purpose To compare the surgical therapeutic effects and complications of lumbarperitoneal shunt (LPS) and the stereotactic ventriculoperitoneal shunt (SVPS) for idiopathic intracranial hypertension.ConclusionCSF diversion with a ventriculoperitoneal shunt (VPS) or lumboperitoneal shunt (LPS) is usually performed when the main symptom is vision loss and it also stabilizes headache and papilledema. LPS significantly alleviates symptoms in the short term, but due to excessive shunt of LPS long time, it is easy to be complicated with iatrogenic Chiari malformation and slit ventricle syndrome. Therefore, we are encouraged to apply the SVPS on our patients for the favorable long-term outcome.

Shunt malfunction and endoscopy

Objective: Hydrocephalus is the most common neurological disease in pediatric neurosurgery.(1) The CSF shunts remains as the most common treatment choice for nonobstructive hydrocephalus worldwide, but shunt complications still the most common neurosurgical problem, especially in pediatric neurosurgery. Endoscopy and shunts are the way to treat hydrocephalus. Especially third ventriculostomy is the most effective treatment to obstructive hydrocephalus but shunt still the most important way to treat.(2, 3) Shunt malfunction is frequent and after so many years this is very important problem to the patients. Ventricular problem due to obstruction is responsible up to 72% of shunt problems.(4) The Shunt Trial Study showed that the overall shunt survival was 62% at 1 year, 52% at 2 years, 46% at 3 years, 41% at 4 years. The survival curves for the 3 differents valves were similar to those from the original trial and did not show a survival advantage for any particular valve.(5, 6) We still don´t have one perfect solution to hydrocephalus and shunt malfunction. The major author described his experience in use endoscopy to evaluate and treat shunt malfunction and one new approach and way to evaluate this problem. Results/Discussion: The literature review was performed, and we found 84 articles when we used the keywords. Endoscopy has been one important way to treat and solve shunt problems. In obstructive hydrocephalus third ventriculostomy is the best way to treat these patients.(1-3) The major author first described goals of endoscopy. First goal is safe catheter removal in surgical review, avoiding bleeding when removing catheter addressing all the adhesions on catheter. Second goal is put in optimal position the new catheter with pure endoscopy view or using neuronavigation systems that could help the endoscope system.(7, 8) Optimal new catheter placement and optimal long-term catheter survival are especially important because most of the problems are due to ventricular problems. These good placements could avoid loculations and ventricular collapse with ependymal problems. Avoid new catheter malpositiitioning, you can use the endoscope to follow the old tract to insert the new catheter in one good position avoiding choroid plexus. Another situation is when you have small ventricles especially in slit ventricle syndrome. The major author has been studied some causes to ventricular catheter obstruction. He noticed after some surgical reviews some ventricular ependymal inside catheter. Ventricular ependymal protrusions inside the catheter could cause intermittent occlusion.(8) Some endoscope views showed these protrusion and ependymal changes after intermittent increase and decrease of ventricular pressure. These protrusions correspond to catheter holes a secondary to suction. These protrusions could stuck in the holes in chronicle suction.(8) The major author reported one endoscopic evidence of overdrainage-related ventricular tissue protrusions that cause partial or complete obstruction of the ventricular catheter. He did a retrospective review in fifty patients underwent 83 endoscopic shunt revision procedures that revealed in-growth of ventricular wall tissue into the catheter tip orifices (ependymal bands), producing partial, complete, or intermittent shunt obstructions. Endoscopic ventricular explorations revealed ependymal bands at various stages of development, which appear to form secondarily to siphoning.(8) How to minimize this overshunting? Anti siphon systems could help and decrease proximal shunt malfunction in some complex patients. The other problem is ventricular bleeding. The use of endoscope has been important tool to remove ventricular catheters, when you could see the adhesions.(9) The use the endoscope could be particularly important to open loculations and cysts avoiding ventricular entrapment. Patients with ventricular cysts could need more than one catheter. The use of endoscopy to fenestrate the cyst could keep the patient with one catheter or without any shunt system.(10, 11) Conclusion: Shunt malfunction has a lot of possible causes, but a probably ventricular catheter problem is the most common situation. Choose appropriate endoscope rigid or flexible for each case could help to treat and avoid some of ventricular. Endoscopy could be one important tool to help the surgeon to understand and solve this dangerous situation to the patient. Ventricular wall protrusions are a significant cause of proximal shunt obstruction, and they appear to be caused by siphoning of surrounding tissue into the ventricular catheter orifices.

Comparison of Lumboperitoneal Shunt and Stereotactic Ventriculoperitoneal Shunt in the Treatment of Refractory Idiopathic Intracranial Hypertension: A Case Report and Literature Review

Idiopathic Intracranial Hypertension (IIH) or Pseudotumor Cerebri (PTC) is a disorder of young obese females and characterized by headache, papilledema and raised intracranial pressure. However, it is in the absence of known pathological cause. Due to the uncertainty of etiology, it may lead to misdiagnosis and grave clinical prognosis. IIH is typically treated with Lumboperitoneal Shunting (LPS) and Ventriculoperitoneal Shunting (VPS), but shunts are prone to dysfunctions and infection, resulting in recurrent headaches in many patients after this treatment. We report a case of 41-year-old obese female (BMI: 30.9) with IIH, who has a history of hypertension (Blood pressure: 150/100 mmHg) and elevated intracranial pressure (Open pressure: 450 mmH2 O). After the failure of several medical treatments, the patient was offered LPS because of vision loss and headache, but the postoperative symptoms (intermittent headache, mainly total craniocerebral prickling pain with neck and shoulder pain) were not significantly relieved for 11 years. Therefore, considering the blockage of the primary shunt tube and the small ventricle in the patient, it has difficulty in puncture ventricle puncture. We have to treat with the stereotactic VPS (SVPS) for her exacerbation symptoms. More surprisingly, the hypertension was in the normal range (<115/80 mmHg) after the surgery (without taking antihypertensive medication). To compare the surgical therapeutic effects and complications of LPS and the SVPS in the treatment of idiopathic intracranial hypertension. Cerebrospinal Fluid (CSF) diversion with VPS or LPS is usually performed when the main symptom is vision loss; it also stabilizes headache and papilledema. LPS significantly alleviates symptoms in the short term, but due to excessive shunt of LPS for a long time, it is easy to be complicated with Chiari malformation and slit ventricle syndrome. Therefore, we encourage operating the SVPS on our patients for the favorable long-term outcome.

Predictors of fast and ultrafast shunt failure in pediatric hydrocephalus: a Hydrocephalus Clinical Research Network study

OBJECTIVEThe primary objective of this study was to use the prospective Hydrocephalus Clinical Research Network (HCRN) registry to determine clinical predictors of fast time to shunt failure (≤ 30 days from last revision) and ultrafast time to failure (≤ 7 days from last revision).METHODSRevisions (including those due to infection) to permanent shunt placements that occurred between April 2008 and November 2017 for patients whose entire shunt experience was recorded in the registry were analyzed. All registry data provided at the time of initial shunt placement and subsequent revision were reviewed. Key variables analyzed included etiology of hydrocephalus, age at time of initial shunt placement, presence of slit ventricles on imaging at revision, whether the ventricles were enlarged at the time of revision, and presence of prior fast failure events. Univariable and multivariable analyses were performed to find key predictors of fast and ultrafast failure events.RESULTSA cohort of 1030 patients with initial shunt insertions experienced a total of 1995 revisions. Of the 1978 revision events with complete records, 1216 (61.5%) shunts remained functional for more than 1 year, and 762 (38.5%) failed within 1 year of the procedure date. Of those that failed within 1 year, 423 (55.5%) failed slowly (31–365 days) and 339 (44.5%) failed fast (≤ 30 days). Of the fast failures, 131 (38.6%) were ultrafast (≤ 7 days). In the multivariable analysis specified a priori, etiology of hydrocephalus (p = 0.005) and previous failure history (p = 0.011) were independently associated with fast failure. Age at time of procedure (p = 0.042) and etiology of hydrocephalus (p = 0.004) were independently associated with ultrafast failure. These relationships in both a priori models were supported by the data-driven multivariable models as well.CONCLUSIONSNeither the presence of slit ventricle syndrome nor ventricular enlargement at the time of shunt failure appears to be a significant predictor of repeated, rapid shunt revisions. Age at the time of procedure, etiology of hydrocephalus, and the history of previous failure events seem to be important predictors of fast and ultrafast shunt failure. Further work is required to understand the mechanisms of these risk factors as well as mitigation strategies.

Decompressive Cranial Vault Remodeling in Osteosclerotic Robinow Syndrome

We present a novel application of endocranial burr contouring for cranial vault expansion as a surgical adjunct during decompressive craniectomy in patients with cranial osteosclerosis. A 16-year-old female with osteosclerotic Robinow syndrome complicated by slit ventricle syndrome presented with refractory intracranial hypertension following external ventricular drain placement. Symptoms included severe headaches and altered mental status. Given the severe intracranial volume restriction secondary to massive calvarial thickening (2.5 cm), the patient was taken to the operating room for urgent surgical decompression. After frontal and parietal craniectomy, burr and osteotome contouring were used to remove two-thirds of the endocranial calvarial bone flap thickness resulting in a 9% cranial vault expansion while preserving an overall normal head size. There were no immediate postoperative complications. At over 3 years postoperatively, the patient had reduced headaches, maintained adequate shunt function, and has not required further vault reconstruction.