Neuroendoscopic Navigated One-Step Removal of Crossed Ventricular Catheter Fragments: Technical Note

Introduction Neuroendoscopy plays an important role in minimally invasive neurosurgery. The authors reported an interesting case of a pediatric patient with multiple ventriculoperitoneal shunt (VPS) revision surgeries, presenting with VPS infection and with two crossed intraventricular floating catheter fragments, successfully removed through a neuroendoscopic navigated one-step procedure. A literature review regarding this exceedingly rare condition has also been discussed. Case Description An 11-year-old female patient with a history of congenital hydrocephalus was admitted to the emergency department with symptoms of intracranial hypertension, psychomotor agitation, and tetraparesis. She had a history of previous multiple VPS revisions. She had an urgent brain computed tomography scan that documented hydrocephalus; the VPS's intraventricular catheter tip was sited at the level of the right frontal horn. Two small floating catheter fragments, not connected to the VPS, were identified: the first close to the right lateral ventricle at the level of the right occipital horn, the second one between the right occipital horn and the third ventricle. First, she underwent an exteriorization of the distal catheter for VPS. Cerebrospinal fluid examination documented hyperproteinorrachia and a positive culture for Staphylococcus aureus. Then a navigated right transfrontal endoscopic approach to the right lateral ventricle was performed extending to the previous burr hole and achieving a wide range of working angle with a rigid 0-degree lens endoscope. Intermittent irrigation generating convective flow was performed such as to mobilize the catheters tip gently upward, to remove them by grasping. Finally, a whole VPS replacement has been performed. Conclusion Persistence of intraventricular floating catheter fragments can lead to subacute or chronic infections. Neuroendoscopic retrieval represents a safe and effective alternative to a more extensive and invasive surgical approach. However, the exact catheter tip identification, grasping, and removal can be difficult to achieve, due to the technical instrumentation characteristics and altered intraventricular anatomy in chronic congenital hydrocephalus. In our experience, endoscopic convective flow induction through saline irrigation can determine floating intraventricular catheter fragments movement aiming to their identification and subsequent successful endoscopic retrieval.

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.

Endovascular retrieval of a broken distal ventriculoatrial shunt catheter within the heart: illustrative case

BACKGROUND Displacement of a distal catheter of a ventriculoatrial (VA) shunt is a rare complication and can lead to a challenging extraction requiring endovascular retrieval of the distal catheter. OBSERVATIONS The authors describe a patient in whom the distal catheter of the VA shunt had become displaced and traveled through the tricuspid valve into the right ventricular outflow tract. LESSONS In this case report, the authors present a multidisciplinary approach to retrieving a displaced distal catheter from a VA shunt.

P.207 Reducing the risks of proximal and distal shunt failure in adult hydrocephalus: A Shunt Outcomes Quality Improvement (ShOut-QI) Study

Background: Ventriculoperitoneal (VP) shunt failures in adult patients are common and subject patients to multiple surgeries and a decreased quality of life. A prospective cohort Shunt Outcomes Quality Improvement (ShOut-QI) initiative was implemented to reduce shunt failure incidence through neuronavigation-assisted proximal catheter insertion and laparoscopy-guided distal catheter anchoring over the liver dome to drain CSF away from the omentum. Methods: “Pre-ShOut” and “Post-ShOut” groups of patients included those with and without neuronavigation/laparoscopy, respectively for insertion of a new VP shunt. The primary outcome was shunt failure which was defined as any return to surgery for shunt revision as determined with a standardized clinical and radiology follow-up protocol. Results: 244 patients (97 Pre-ShOut, 147 Post-ShOut), mean age 73 years, were enrolled over a 7-year interval and observed for a mean duration of 4 years after shunt insertion. Neuronavigation improved proximal catheter placement accuracy by 20% (p<.001), and shunt failure occurred in 57% vs 23% in the Pre-ShOut and Post-ShOut groups, respectively (p=.008), representing a 53% relative risk reduction in the incidence of shunt failure. Conclusions: Adult shunt failure incidence may be significantly reduced by improving the accuracy of proximal catheter placement with neuronavigation and reducing the risk of distal catheter failure with laparoscopic-guided placement.

Umbilical hernia causing ventriculoperitoneal shunt dysfunction: illustrative cases

BACKGROUND When ventriculoperitoneal (VP) shunts and umbilical hernias coexist in the same patient, unique complications can occur. Typically, these are readily identified problems such as cerebrospinal fluid (CSF) fistulas or entrapment of the peritoneal catheter in the hernia. The authors present cases of two children whose VP shunt dysfunction resolved after repair of their umbilical hernias. OBSERVATIONS The authors present two cases of infant patients with shunted hydrocephalus and umbilical hernias. In both cases, the patients presented with distal shunt malfunctions not due to infection. Their shunt function improved once the umbilical hernia was repaired by pediatric surgery. Neither has required shunt revision since umbilical hernia repair. LESSONS Although there are case reports of VP shunts eroding through the umbilicus, developing CSF fistulas, or becoming trapped inside umbilical hernias, there is no case of VP shunt dysfunction caused by just the presence of an umbilical hernia. The authors suspect that the catheter may intermittently enter and exit the hernia. This may cause intermittent obstruction of the distal catheter, or inflammation in the hernia may occur that limits CSF absorption.

Rare complication of ventriculoperitoneal shunt: Ectopic distal catheter in a Grynfeltt hernia – case report

Background: Ventriculoperitoneal shunts (VPSs) insertion is the most common used intervention in cases of hydrocephalus. The main postoperative complications are infections and catheter obstructions. Although the literature has well-documented cases describing migration of the distal catheter, this rare presentation can become more confusing when occurring in conjunction with some unusual preexistent morbidity in the patient, as a Grynfeltt hernia. Case Description: This study reports a rare case of a VPS postoperative migration, in which the distal catheter exits the abdominal cavity through a Grynfeltt hernia. This condition was not discovered until the catheter fistulated through the overlying skin. The Grynfeltt hernia is the most uncommon among the lumbar ones and it’s asymptomatic in the majority of the cases, being hardly diagnosed. Conclusion: The unusualness of the reported case deserves furthermore discussion to properly evaluate these underlying mechanisms of catheter migration.

Neuromonitoring During Cardiac Surgery in a Patient with Ventriculo-Caval Shunt Migration: Case Report

Ventricular shunting is a well-recognised and commonly practiced method of reducing increased intracranial pressure in patients with neurologic pathology. There are possible complications related to shunt implantation, where the rarest is intracardiac migration of the distal shunt catheter. We present a case where the distal catheter migrated into the right ventricle, causing extrasystoles and was complicated with acute right ventricle failure during the endovascular shunt evacuation procedure.

Cardiovascular catheter stiffness – a static measurement approach

Catheters are widely used for therapeutic and diagnostic purposes in various medical applications. Along with frictional properties as well as the catheter profile the catheter stiffness mainly affects the deliverability and thus, the handling properties of the catheter. Within this study the bending stiffness of proximal and distal catheter samples was investigated with a custom made test setup. In particular, the influence of the catheter clamping length on the test results is discussed. Bending stiffness was calculated directly from the measured force, deflection and clamping length considering the test setup compliance. Measurements were performed three times at five positions in circumferential direction. Measured bending stiffness ranged from 629 ± 31 Nmm² to 733 ± 58 Nmm² for the proximal samples and from 30 ± 5 Nmm² to 98 ± 30 Nmm² for the distal samples, respectively. Bending stiffness varied depending on the free catheter length and the reaction force measured. The maximum reaction force decreased with increasing free catheter length leading to a higher measurement uncertainty. However, when considering the same free catheter length quantitative results were similar within the group of proximal and distal samples, respectively.

Ventriculopleural shunts in a pediatric population: a review of 170 consecutive patients

OBJECTIVE The authors sought to determine the outcome of using the pleural space as the terminus for ventricular CSF-diverting shunts in a pediatric population. METHODS All ventriculopleural (VPl) shunt insertions or revisions done between 1978 and 2018 in patients at Children’s Hospital Los Angeles were identified. Data recorded for analysis were age, sex, weight, etiology of hydrocephalus, previous shunt history, reason for VPl shunt insertion or conversion from a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt, valve type, nature of malfunction, presence of shunt infection or pleural effusion, and conversion to a different distal site. RESULTS A total of 170 patients (mean age 14 ± 4 years) with a VPl shunt who were followed up for a mean of 57 ± 53 months were identified. The reasons for conversion to a VPl shunt for 167 patients were previous shunt infection in 57 (34%), multiple abdominal procedures in 44 (26%), inadequate absorption of CSF in 34 (20%), abdominal pseudocyst in 25 (15%), and obesity in 7 (4%). No VPl revisions were required in 97 (57%) patients. Of the 73 (43%) patients who did require revision, the most common reason was proximal obstruction in 32 (44%). The next most frequent complication was pleural effusion in 22 (30%) and included 3 patients with shunt infection. All 22 patients with a clinically significant pleural effusion required changing the distal end of the shunt from the pleural space. Pleural effusion was more likely to occur in VPl shunts without an antisiphon valve. Of the 29 children < 10 years old, 7 (24%) developed a pleural effusion requiring a revision of the distal catheter to outside the pleural space compared with 15 (11%) who were older (p = 0.049). There were 14 shunt infections with a rate of 4.2% per procedure and 8.2% per patient. CONCLUSIONS VPl shunts in children younger than 10 years of age have a significantly higher rate of symptomatic pleural effusion, requiring revision of the shunt’s terminus to a different location. VPl shunt complication rates are similar to those of VP shunts. The technical difficulty of inserting a VPl shunt is comparable to that of a VP shunt. In a patient older than 10 years, all else being equal, the authors recommend that the distal end of a shunt be placed into the pleural space rather than the right atrium if the peritoneal cavity is not suitable.