Pseudocyst of Abdomen Presenting as a Huge Abdominal Mass after Ventriculoperitoneal Shunt: A Case Report

A ventriculoperitoneal shunt is a major surgical modality to relieve intracranial pressure in patients with hydrocephalus. Shunt obstruction and infection are the most common complications following shunt surgery whereas VP shunt-associated pseudocyst formation is a rare complication. These are the cystic space without the epithelial lining, filled with fluid around the distal tip of the catheter. In this case report, we present you a 47-year-old male who underwent VP shunt placed a year back presented with huge abdominal swelling, headache, and weight loss. CT scan of the abdomen showed abdominal pseudocyst with the peritoneal end of the shunt within the cyst. Though the exact mechanism is not known, abdominal adhesion, multiple revisions, obstruction, or dislodgement are thought to predispose to the formation of a pseudocyst.

Change in Balance and Neuropsychological Measures Post-Lumbar Drain Trial in Patients with Suspected Normal Pressure Hydrocephalus

<b><i>Objective:</i></b> Ventriculoperitoneal (VP) shunting is commonly used to treat normal pressure hydrocephalus (NPH). Assessment of cognition and balance pre- and post-lumbar drain (LD) can be used to provide objective metrics which may help determine the potential benefit of VP shunting. The aim of this investigation was to determine which measures identify clinical change as a result of a LD trial and to develop recommendations for standard NPH clinical assessment procedures. <b><i>Methods:</i></b> The Berg Balance Scale (BBS) and a brief battery of commonly used neuropsychological tests pre- and post-LD (MMSE, trail making test, animal fluency, Hopkins Verbal Learning Test – Revised, and digit span) were administered to 86 patients with a diagnosis of NPH. Subjects were divided into groups based on whether or not clinical change was present, and thus, VP shunting was recommended post-LD, and predictors of group membership were examined. <b><i>Results:</i></b> Significant improvements (<i>p</i> &#x3c; 0.05) were seen on the BBS and Trail Making Part B in the VP shunt-recommended group, with no other significant changes over time in either group. Regression analyses found that VP shunt recommendation was accurately predicted for 80% of the sample using the BBS score alone, with accuracy increasing to 85% when Trails B was added. <b><i>Conclusions:</i></b> Scores from the BBS and Trails B were most likely to change in those chosen to undergo VP shunting post-LD. Given that the typical clinical presentation of NPH includes gait disturbance and cognitive impairment, it is recommended that a standard pre-/post-LD evaluation include the BBS and trail making test.

Successful management of symptomatic hydrocephalus using a temporary external ventricular drain with or without endoscopic third ventriculostomy in pediatric patients with germinoma

OBJECTIVE The objective of this study was to describe the management of hydrocephalus in a cohort of pediatric patients with germinoma. METHODS The authors conducted a retrospective chart review of patients with germinoma and symptomatic hydrocephalus treated at the Hospital for Sick Children between 2002 and 2020. Descriptive data included tumor location, CSF diversion procedure (external ventricular drain [EVD], endoscopic third ventriculostomy [ETV], ventriculoperitoneal [VP] shunt) and outcomes. The frontooccipital horn ratio (FOR) method was used to determine the presence of ventriculomegaly. RESULTS Of 39 patients with germinoma, 22 (73% male) had symptomatic hydrocephalus at diagnosis (11 pineal, 4 suprasellar, and 7 bifocal). Management of hydrocephalus included EVD (n = 5, 22.7%), ETV (n = 5, 22.7%), and combination ETV and EVD (n = 7, 31.8%), whereas 5 patients (22.7%) did not undergo surgical intervention. The median FOR at diagnosis was 0.42 (range 0.38–0.58), which correlated with moderate to severe ventriculomegaly. Carboplatin and etoposide–based chemotherapy induced fast tumor shrinkage, avoiding CSF diversion (n = 5) and resolving hydrocephalus with a transient EVD (n = 5). The median duration until EVD removal was 7 days (range 2–10 days). Two of 12 patients with EVD ultimately required a VP shunt. Kaplan-Meier overall survival was 100% and progression-free survival was 96.4% at a median follow-up of 10.4 years. CONCLUSIONS Timely initiation of chemotherapy is imperative to rapidly reduce tumor bulk in children with germinoma and limits the need for VP shunt insertions. In children in whom CSF diversion is required, hydrocephalus may be successfully managed with a temporary EVD ± ETV.

Changes in computed tomography perfusion parameters and maximum contrast enhancement in patients having hydrocephalus with a ventriculoperitoneal shunt: a pilot study

Background Acute hydrocephalus may decrease cerebral perfusion by increasing intracranial pressure. Computed tomography perfusion (CTP) has become a significant adjunct in evaluating regional and global cerebral blood flow (CBF). Purpose To investigate the changes in cerebral perfusion parameters and maximum contrast enhancement (MCE) in patients with hydrocephalus with ventriculoperitoneal shunt (VPS). Material and Methods We performed brain CTP in 45 patients, including those with subarachnoid hemorrhage (SAH)-induced hydrocephalus with VPS (n = 14, G1), hydrocephalus (not related to SAH) with VPS (n = 11, G2), SAH-induced hydrocephalus without VPS (n = 10, G3), and hydrocephalus (not related to SAH) without VPS (n = 10, G4). We measured the cerebral perfusion in the frontal white matter (FWM), centrum semiovale, basal ganglia (BG), and eight cortical lesions of interest and compared the differences in CTP parameters among the groups. Results Between the four groups, cerebral blood volume and MCE in the left FWM and CBF in the right FWM increased significantly in G1 and G2 who underwent VP shunt compared to G3 and G4, whereas perfusion significantly reduced in G3 and G4 who did not undergo VP shunt compared to G1 and G2. MCE in the left BG significantly increased in G2 and decreased in G3 and G4. SAH-induced hydrocephalus showed a lower perfusion than hydrocephalus (not related to SAH) in FWM. Conclusions Perfusion changes in patients with hydrocephalus after VP shunt were seen in the FWM and BG, which appears to be the result of the hydrocephalus reducing brain perfusion in the deep part of the brain. We concluded that SAH slows brain perfusion recovery.

Outcomes of Ventriculoperitoneal Shunt in Patients With Idiopathic Normal-Pressure Hydrocephalus 2 Years After Surgery

Objective: To evaluate the outcomes and prognostic factors of ventriculoperitoneal shunts (VP-shunts) in patients with idiopathic normal-pressure hydrocephalus (iNPH) at 6 months and 2 years after surgery.Method: We retrospectively analyzed 68 patients admitted to our institute and diagnosed with probable iNPH from January 2017 to March 2021. All patients underwent VP-shunt surgery with a programmable valve, and their outcomes were assessed via the Krauss index and modified Rankin scale (mRS) at 6 months and 2 years post-surgery. Univariate and multivariate regression analysis was performed to identify the prognostic factors.Results: The mean age of the patients was 71.1 ± 8.4 (mean ± standard deviation) years. On the Krauss improvement index, 6-month follow-up results were available for 68 patients. Of these patients, 91.2% experienced attenuation of their preoperative symptoms, with a mean Krauss index of 0.58 ± 0.27, and 48 patients (70.6%) had a Krauss index ≥0.5. Two-year follow-up results were available for 33 patients; 90.9% of them had sustained improvement, with a Krauss index of 0.54 ± 0.31, and 21 patients (66.3%) had a Krauss index ≥0.5. Thirty-three patients (58%) were living independently after 2 years (mRS 0–2). The outcomes were worse for patients with multiple comorbidities. Neither an increased patient age nor a prolonged history of illness was statistically significant prognostic factors for adverse outcomes of VP-shunt surgery.Conclusion: Surgical treatment was well-tolerated by patients with iNPH who received VP-shunts. Most patients experienced attenuation of their preoperative symptoms. Multiple concurrent comorbidities should be considered as adverse prognostic factors before shunt insertion in patients with iNPH.

Differences in Outcome Between Open vs Laparoscopic Insertion of Ventriculoperitoneal Shunts

Background Abdominal access during ventriculoperitoneal (VP) shunt insertion has historically been obtained by neurosurgeons via an open abdominal approach. With recent advances in laparoscopy, neurosurgeons frequently consult general surgery for aid during the procedure. The goal of this study is to identify if laparoscopic assistance improves the overall outcomes of the procedure. Methods This retrospective study included all patients who underwent open or laparoscopic VP shunt placement between September 2012 and August 2020 at our tertiary referral hospital. Patient demographics, comorbidities, prior history of abdominal surgery, open vs. laparoscopic insertion, operation time, and complications within 30 days were obtained. Results Neurosurgery placed 107 shunts using an open abdominal technique and general surgery placed 78 using laparoscopy. The average OR time in minutes was 75.5 minutes for the open cohort and 61.8 for the laparoscopic cohort ( p = 0.006). In patients without a history of abdominal surgery, the average OR time in minutes was 79.4 in the open cohort and 57.1 in the laparoscopic cohort ( p = 0.015). The postoperative shunt infection rate was 10.2% in the open group and 3.8% in the laparoscopic group ( p = 0.077). Discussion Laparoscopic placement of VP shunts is a reasonable alternative to open placement and results in shorter OR times. There is also a trend toward few infections in the laparoscopic placement. There appears to be an advantage with a team approach and laparoscopic placement of the peritoneal portion of the shunt.

SURG-06. THE SAFETY PROFILE OF TUMOR TREATING FIELDS (TTFIELDS; 200 KHZ) CONCOMITANT WITH VENTRICULO-PERITONEAL SHUNTS IN PATIENTS WITH GLIOBLASTOMA AND HYDROCEPHALUS

INTRODUCTION Hydrocephalus is a common development in patients with glioblastoma (GBM) requiring treatment with ventriculo-peritoneal (VP)-shunts (programmable/non-programmable). To maximize outcomes in this high-risk population, evaluation of VP-shunt usage concomitant with GBM treatments is necessary. Tumor Treating Fields (TTFields; 200 kHz; anti-mitotic, loco-regional cancer modality) non-invasively delivers continuous, alternating electrical fields per scalp-placed arrays. TTFields treatment has obtained FDA-approval/CE-mark in adult patients with newly-diagnosed GBM (ndGBM) and recurrent GBM (rGBM). Due to insufficient TTFields/VP-shunt usage data, label does not currently advise concurrent use. We report on safety data from adult patients utilizing TTFields/VP-shunts in the real-world, clinical-setting. METHODS This retrospective, post-marketing, safety surveillance analysis evaluated unsolicited data from adult patients with GBM/hydrocephalus who were TTFields-treated in the presence of a VP-shunt. Available data from &gt;18,000 patients with GBM prescribed TTFields (November 1, 2012 to April 15, 2021 [cut-off date]) were screened for eligibility. Included were 156 adult patients (≥ 18 years of age) with confirmed GBM/hydrocephalus and TTFields/VP-shunt (46 programmable; 110 non-programmable/unknown) usage. Patients were further analyzed by diagnosis (ndGBM, n=92; rGBM, n=64). RESULTS Of 156 TTFields/VP-shunt-treated patients (median age 52), 66% were male and 81% from the United States (19%; Europe/Middle-east/Africa). Overall, no TTFields-related shunt-failures or differences by GBM diagnosis in shunt-type and TTFields-related AEs were observed. Commonly-reported TTFields-related adverse events (AEs) &gt;10% were beneath-array skin reactions (∼43%), electric sensations (∼14%; tingling), headache (∼13%), fatigue/malaise (∼12%), and heat sensation (∼11%; warmth); headache and fatigue/malaise are also associated with other concomitant treatments/disease burden. There were 5 serious AEs (all skin AEs) potentially-related to TTFields at the shunt-site (2 events, wound dehiscence; 3 events, skin erosion). CONCLUSIONS Adult patients with GBM/hydrocephalus treated with TTFields (200 kHz)/VP-shunts in the real-world, clinical-setting suggests feasibility and a tolerable safety profile; with no evidence of disrupted VP-shunt effectiveness. TTFields safety profile was consistent with prior-studies.

Neurosurgery

This chapter discusses the anaesthetic management of neurosurgery. It begins with general principles of neurosurgery, including management of intracranial pressure. Surgical procedures covered include craniotomy (including awake craniotomy); insertion of ventriculo-peritoneal (VP) shunt; evacuation of traumatic intracranial haematoma; pituitary surgery; posterior fossa surgery; and interventional radiology treatment of intracranial vascular lesions (with particular attention to subarachnoid haemorrhage (SAH)). The management of venous air embolism is described, along with a discussion of the particular circumstance of resuscitation during neurosurgery.

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.