Ventriculo-atrial shunt. Comparison of an ultrasound-guided peel-away technique versus conventional technique in the management of normal pressure hydrocephalus: A retrospective cohort

Background: Normal pressure hydrocephalus (NPH) is a common neurodegenerative syndrome among the elderly characterized by ventriculomegaly and the classic triad of symmetric gait disturbance, cognitive decline and urinary incontinence. To date, the only effective treatment is a cerebrospinal fluid shunting procedure that can either be ventriculo-atrial, ventriculo-peritoneal, or lumbo-peritoneal shunt. The conventional ventriculo-atrial shunt uses venodissection, whereas the peel-away is a percutaneous ultrasound (US)-guided technique that shows some advantages over conventional technique. We sought to compare perioperative complication rates, mean operating time and clinical outcomes for both techniques in NPH patients at our institution. Methods: A retrospective cohort-type analytical study was conducted, using clinical record data of patients diagnosed with NPH and treated at our center from January 2009 to September 2019. Parameters to be compared include: Perioperative complication rates, intraoperative bleeding, mortality, and mean operating time. Perioperative complication rates are those device-related such as shunt infection, dysfunction, and those associated with the procedure. Complications are further classified in immediate (occurring during the first inpatient stay), early (within the first 30 days of surgery), and late (after day 30 of surgery). Results: A total of 123 patients underwent ventriculo-atrial shunt. Eighty-two patients (67%) underwent conventional venodissection technique and 41 patients (33%) underwent a peel-away technique. Immediate complications were 3 (3.6%) and 0 for conventional and peel-away groups, respectively. Early complications were 0 and 1 (2.4%) for conventional and peel-away groups, respectively. Late complications were 5 (6.1%) and 2 (4.9%) for conventional and peel-away groups, respectively. Mean operating time was lower in the peel-away group (P = 0.0000) and mortality was 0 for both groups. Conclusion: Ventriculo-atrial shunt is an effective procedure for patients with NPH. When comparing the conventional venodissection technique with a percutaneous US-guided peel-away technique, the latter offers advantages such as shorter operating time and lower perioperative complication rates.

Pioneer shunt implantation surgery in Brazil

One of the first experiences of shunt implantation in the world occurred in 1949, by Nulsen and Spitz, who implanted a rubber catheter with a ball valve system, from the lateral ventricle to the internal jugular vein [1]. In the 1950s, the shunt systems had great development, especially the Spitz-Holter system, first used in 1956, consisting of the first system produced on a large scale. The second patient who benefited from this new system was Holter's son Casey, who had myelomeningocele [2,3]. From these first American reports, the shunt surgery had great worldwide dissemination in the 1960s. One of the first CSF shunts in Brazil and Latin America occurred in 1966, in the city of Uberaba, Minas Gerais, by Prof. Francisco Mauro Guerra Terra, founder of the Chair of Neurosurgery at Triângulo Mineiro Medical School, today part of Federal University of Triângulo Mineiro (UFTM). The procedure was performed at the Children's Hospital of Uberaba, at the time one of University Hospitals, and the patient was a 7-month-old baby named Maria Beatriz. The child suffered from hydrocephalus, as a complication of tuberculous meningitis, and was diagnosed by pneumoventriculography, a procedure described by Dandy, and widely used in the era before tomography [4] (Fig. 1). The child was submitted to a ventriculo-atrial shunt (Figs. 2, 3 and 4), with implantation of a catheter without a valve, an option widely used at the time. Besides Prof. Guerra, the surgical team was composed by the then medical students Jaime Olavo Marquez, later titular of the Neurology Department of UFTM, Antônio Luiz da Costa Sobrinho, later a neurosurgeon, who later settled in Presidente Prudente, São Paulo, Brazil Carlos Antunes de Paula, also later a neurosurgeon, who settled in the city of Santos, São Paulo, Brazil and the anesthesiologist Dr. Newton Camargo Araújo, from Uberaba (Fig. 5). There is a postoperative image of the case, showing the success of the procedure (Fig. 6). The surgery had great repercussion in the national media at the time (Fig. 7).

Higher Incidence of Atrial Fibrillation in Left Ventricular-to-Right Atrial Shunt Patients

Background: The possible association between atrial fibrillation (AF) and left ventricular-to-right atrial shunt (LVRAS) has never been reported yet. The present study investigated the incidence of AF in LVRAS.Methods: This was a retrospective study of consecutive patients undergoing echocardiography at a single tertiary center. Clinical data, laboratory results and echocardiography parameters such as right atrial area (RAA), right ventricular end diastolic diameter (RVDD) and left atrial diameter (LAD) were compared between LVRAS group and non-LVRAS patients, and between AF and non-AF patients. Propensity score matching was performed to decrease the effect of confounders. Logistic regression analysis and mediation analysis were used to estimate the relationship between LVRAS and AF.Results: A total of 3,436 patients were included, and the incidence of LVRAS was 1.16% (n = 40). The LVRAS group had significantly larger RAA, RVDD and LAD compared with non-LVRAS group. Those who suffered from AF showed larger RAA, RVDD and LAD compared with those who maintained sinus rhythm. Multivariable logistic regression showed that gender (OR: 0.608), age (OR: 1.048), LAD (OR: 1.111), mean pulmonary artery blood pressure (mPAP, OR: 1.023), TR (OR: 2.309) and LVRAS (OR: 12.217) were significant factors for AF. RAA could partially mediate the relationship between LVRAS and AF according to the result of mediation analysis.Conclusions: Our study suggested that LVRAS, TR, LAD, mPAP, age and male were risk factors for AF. RA enlargement might underlie mechanism in the higher incidence of AF in LVRAS patients. These findings should be confirmed in larger prospective studies.

Impending Paradoxical Embolism: Perioperative Management and Role of Transesophageal Echocardiography

Impending paradoxical embolism is a rare but potentially life-threatening complication of venous thromboembolism that is usually associated with acute pulmonary embolism and a right to left atrial shunt. Patients may have associated right ventricular pressure or volume overload with subsequent failure. Transesophageal echocardiography is the preferred diagnostic test of choice in this patient group. Definitive management has yet to be clearly defined. However, emergent surgical removal of the entrapped intracardiac blood thrombus may be necessary. In this article, we review a case of impending paradoxical embolism managed surgically and describe the perioperative anesthetic considerations in this patient population, along with the role of intraoperative transesophageal echocardiography.

Atrial septal defect closure in a young patient presenting with recurrent cryptogenic stroke: A case report

Background: Having an inter-atrial shunt in the form of a patent foramen ovale or atrial septal defect increases the risk of developing cryptogenic stroke. Prompt action is required in order to prevent stroke recurrence. The source of embolization may not be clear on stroke workup.Case presentation: A young female acutely presented with recurrent embolizations to the eye and brain. She was found to have an atrial septal defect. No clear intra-cardiac source of embolization was detected on workup including trans-esophageal echocardiography. Given the options between surgical versus device closure, the attending team opted for the surgical closure which yielded on direct left heart inspection small organized clots adherent to the tips of the mitral valve leaflets. Conclusions: The case report illustrates the potential advantages of the direct surgical closure in detecting and extracting the embolization source in patients who present with recurrent cryptogenic stroke.

Subependymal giant cell astrocytoma associated with hyperproteinorrhachia, presented with vp shunt malfunction: a rare clinical entity

Subependymal giant cell astrocytomas (SEGAs) are WHO grade I tumors, most frequently associated with tuberous sclerosis complex (TSC). TSC sometimes also called Bourneville’s disease is a neurocutaneous disorder characterized by hamartoma of many organs like skin, brain, eye and kidneys. In this report, we illustrate the case of SEGA with hydrocephalus, who presented with features of raised intracranial pressure, along with shunt malfunction due to shunt valve blockage with proteinaceous material. Patient underwent interhemispheric transcallosal approach and complete removal of tumor followed by ventriculo- atrial shunt and achieved favourable outcome.