UpToDate: Shunt dependency syndrome

Shunt dependency syndrome

Intraventricular hemorrhage (IVH) is a common affliction of preterm infants and often results in posthemorrhagic hydrocephalus (PHH). These patients typically eventually require permanent CSF diversion and are presumed to be indefinitely shunt-dependent.

In a cohort of patients with clinical grade aneurysmal subarachnoid hemorrhage (aSAH) at admission, larger amounts of subarachnoid blood and large ventricular size on preoperative cerebral CT, and CSF drainage in excess of 1,500 ml during the 1st week after the ictus were significant predictors of shunt dependency. Shunt dependency did not hamper outcome 1).

Aneurysmal subarachnoid hemorrhage (SAH) has been reported to induce an intrathecal inflammatory reaction reflected by cytokine release, particularly interleukin 6 (IL-6), which correlates with early brain damage and poor outcome.

CSF IL-6 values of ≥10,000 pg/ml in the early post-SAH period may be a useful diagnostic tool for predicting shunt dependency in patients with acute posthemorrhagic hydrocephalus. The development of shunt-dependent posthemorrhagic hydrocephalus remains a multifactorial process 2).

Graeb Score or LeRoux scores improve the prediction of shunt dependency and in parts of case fatality rate (CFR) in aneurysmal SAH patients therefore confirming the relevance of the extent and distribution of intraventricular hemorrhage for the clinical course in SAH 3).

A significantly higher rate of shunt dependency was observed for age older than 65 years, poor initial neurological status, and thick SAH with presence of initial intraventricular hemorrhage. By understanding these factors related to development of SDHC and results, it is expected that management of aneurysmal SAH will result in a better prognosis 4).

In a study SD after aSAH showed no correlations with three of the parameters previously identified as risk factors for shunt dependent hydrocephalus, namely, the amount of SAH, the presence of IVH, or acute hydrocephalus. Instead, a longer duration of CSF drainage correlated with SD as an independent factor. These data suggest that a longer duration of CSF drainage may be one of the risk factors for SD after aSAH 5).

Case series

2015

A total of 471 patients who were part of the Barrow Ruptured Aneurysm Trial (BRAT) from 2003 to 2007 were retrospectively reviewed. All variables including demographic data, medical history, treatment, imaging, and functional outcomes were included as part of the trial. No additional variables were retrospectively collected.

Ultimately, 147 patients (31.2%) required a ventriculoperitoneal shunt (VPS) in this series. Age, dissecting aneurysm type, ruptured vertebrobasilar aneurysm, Fisher grade, Hunt and Hess grade, admission intraventricular hemorrhage, admission intraparenchymal hemorrhage, blood in the fourth ventricle on admission, perioperative ventriculostomy, and hemicraniectomy were significant risk factors (P < .05) associated with shunt-dependent hydrocephalus on univariate analysis. On multivariate analysis, intraventricular hemorrhage and intraparenchymal hemorrhage were independent risk factors for shunt dependency (P < .05). Clipping vs coiling treatment was not statistically associated with VPS after SAH on both univariate and multivariate analyses. Patients who did not receive a VPS at discharge had higher Glasgow Outcome Scale and Barthel Index scores and were more likely to be functionally independent and to return to work 72 months after surgery (P < .05).

There is no difference in shunt dependency after SAH among patients treated by endovascular or microsurgical means. Patients in whom shunt-dependent hydrocephalus does not develop after SAH tend to have improved long-term functional outcomes 6).


Wang et al. analyzed retrospectively collected data for 89 preterm patients diagnosed with grades III and IV IVH and PHH from 1998 to 2011.

Sixty-nine out of 89 patients (77.5 %) underwent ventriculoperitoneal shunt placement, and 33 (47.8 %) required at least one shunt revision and 18 (26.1 %) required multiple revisions. The mean ± standard deviation follow-up time for shunted patients was 5.0 ± 3.3 years. The majority of early failures were due to proximal catheter malfunction, while later failures were mostly due to distal catheter problems. There was a significant difference in the number of patients requiring revisions in the first 3 years following initial VP shunt insertion compared after 3 years, with 28 revisions versus 10 (p < 0.004). In 8 out of 10 patients who underwent shunt revisions after 3 years, evidence of obstructive hydrocephalus was found on imaging either in the form of an isolated fourth ventricular cyst or aqueductal stenosis.

The results suggest that in a distinct subset of patients with PHH, obstructive hydrocephalus may develop, resulting in long-term dependence on CSF diversion. Further study on the factors associated with long-term shunt dependence and revision requirements within the PHH group is warranted 7).

2014

88 consecutive patients with aneurysmal SAH requiring external ventricular drain placement and endovascular aneurysm closure were included. Functional outcome and shunt dependency were assessed 90 days after event. A matched controlled sub-analysis was carried out to investigate the effects of IVF treatment (n = 14; matching criteria: age, neuro-status and imaging). Multivariate modeling was performed to identify independent predictors for permanent shunt dependency.

In IVF-patients neurological status was significantly poorer [Hunt&Hess: IVF = 4(3-5) vs. non-IVF = 3(1-5); p = 0.035] and the extent of ventricular hemorrhage was increased [Graeb Score: IVF = 7(6-8) vs. non-IVF = 3(1-4); p ≤ 0.001]. Consecutive matched controlled sub-analysis revealed no significant therapeutic effect of IVF with respect to shunt dependency rate and functional outcome. Multivariate analysis revealed Graeb score [OR = 1.34(1.02-1.76); p = 0.035] and sepsis [OR = 11.23(2.28-55.27); p = 0.003] as independent predictors for shunt dependency, whereas IVF did not exert significant effects (p = 0.820).

In endovascular-treated SAH patients IVF neither reduced permanent shunt dependency nor influenced functional outcome. Despite established effects on intraventricular clot resolution IVF appears less powerful in SAH as compared to ICH. Given the reported positive effects of lumbar drainage (LD) in SAH, a prospective analysis of a combined treatment approach of IVF and subsequent lumbar drain sOeems warranted aiming to reduce permanent shunting and improve functional outcome 8).

1999

Of 138 patients treated for ruptured aneurysms the development of shunt dependent hydrocephalus was evaluated regarding possible predictive factors. In 15 patients (11%) ventriculo-atrial shunt was implanted due to hydrocephalus. One predictive factor was the localisation of aneurysms as patients with hydrocephalus had PcoA aneurysms in 40% compared to 20% in the group of patients without hydrocephalus and only 7% compared to 28% MCA aneurysms. An other predictive factor was the severity of the subarachnoid haemorrhage (SAH) as 7 patients out of the 15 were graded Fisher IV on admission. Furthermore, an important predictive factor was the presence of acute hydrocephalus as 13 out of the 15 patients (87%) with shunt dependent hydrocephalus had acute hydrocephalus requiring external ventricular drainage. An other possible factor was the intraoperative opening of the lamina terminalis as in 73% of the patients with shunt dependent hydrocephalus compared to 82% in the group of patients without hydrocephalus this procedure was performed during surgery. The results suggest that shunt dependency is more likely after severe SAH especially in the presence of an acute hydrocephalus and in patients with aneurysms located in the basal cisterns. Therefore treatment of the acute hydrocephalus and possible the opening of the lamina terminalis could have a positive effect on the development of shunt dependent hydrocephalus after SAH 9).

1979

Five patients with shunt dependency were observed to have apparently normal ventricular size despite marked increases in ventricular pressure after shunt malfunctionElastance (dP/dV) was determined in four of these patients by removing increments of cerebrospinal fluid and measuring the resulting pressure. These patients without ventricular enlargement and with markedly increased ventricular pressure had high elastance. This group of patients with “normal volume” hydrocephalus had distal shunt occlusions, in contrast to previously reported patients with cephalic shunt obstructions after ventricular decompression. Initial shunting in early infancy, prolonged shunt dependency, and lack of recent shunt revision were common factors in these patients. Markedly elevated pressure with normal volume is a threatening clinical entity, requiring prompt surgical intervention 10).

1975

In suitable cases, intermittent cranial compression by means of an elastic bandage or a helmet with an inflatable inner-lining may be effective. There was arrested hydrocephalus in nine of 14 children treated with this method, eight of whom have developed normally. When cranial compression is contra-indicated or not successful, the preferred method of treatment is an ‘on-off’ type of valve which is used intermittently to drain a fixed volume of cerebrospinal fluid. Of 18 children who had such shunts inserted, 10 have become totally independent of their shunts and their hydrocephalus has become compensated. All are of normal intelligence. Subtemporal craniectomy was performed on seven shunt-dependent children with recurrent catheter obstruction. Four have been followed for six months and three for two years and in no case has there been further malfunction of the proximal catheter 11).

Case reports

Dong et al., from the Tongji Hospital, Huazhong University of Science and Technology, WuhanChina report two children with middle fossa arachnoid cysts who underwent cystoperitoneal shunt with fixed pressure valve at an opening pressure of 7 cmH2O and then developed dependency syndrome. Both patients were effectively treated by mini-invasive cyst wall excision with the shunts reserved. The clinical manifestation, radiological findings, treatment methods, and therapeutic outcomes were reviewed retrospectively.

The time from shunt surgery to shunt dependency syndrome occurrence was 4 and 2 years, respectively. Computed tomography/magnetic resonance findings of the brain showed remarkably collapsed cysts with normal or small ventricles. Both patients underwent secondary mini-invasive cyst wall excision and shunt catheters were reserved. After the operations, their symptoms were resolved except one case with marginally improved visual impairment.

Shunt dependency syndrome is a rare but dangerous complication of CP shunt and should be treated in time. Collapsed and thickened cyst wall intermittent covering the catheter head end, decreased brain compliance due to chronic fibrosis, as well as regression of cerebrospinal fluidabsorption could be the pathogenesis. They suggest keyhole resection of the residual cyst wall as an effective and mini-invasive treatment option12).


Sonobe et al. report two cases of high shunt dependency, which were first thought to be shunt independent arrested hydrocephalus. Though their shunt systems didn’t seem to work, symptoms of rapid increasing intracranial pressure were observed after obstruction or replacement of shunt tube. Their ventricles looked so small like a slit on CT scan and PVG that the apex of the ventricular tube were easily obstructed by a ventricle wall. This is the reason why we misjudged them to be shunt independent arrested hydrocephalus. The cause of slit-like ventricles was overflow of CSF fluid due to the low pressure valve and the siphon effect. In general, after the shunt operation, most of the cases with thickening of cerebral mantle show the shunt dependency. Especially the cases showing rapid and marked thickening of the cerebral mantle are highly shunt dependent. Therefore, we must observe such cases carefully, in which the ventricle becomes small. Short interval follow-ups by CT scan after the shunt operation are quite necessary in order to observe the ventricle size. Easy and reliable judging method to know whether the shunt system is working or not is required to be developed 13).

References

1)

Erixon HO, Sorteberg A, Sorteberg W, Eide PK. Predictors of shunt dependency after aneurysmal subarachnoid hemorrhage: results of a single-center clinical trial. Acta Neurochir (Wien). 2014 Nov;156(11):2059-69. doi: 10.1007/s00701-014-2200-z. Epub 2014 Aug 22. PubMed PMID: 25143185.
2)

Wostrack M, Reeb T, Martin J, Kehl V, Shiban E, Preuss A, Ringel F, Meyer B, Ryang YM. Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: The Role of Intrathecal Interleukin-6. Neurocrit Care. 2014 May 20. [Epub ahead of print] PubMed PMID: 24840896.
3)

Czorlich P, Ricklefs F, Reitz M, Vettorazzi E, Abboud T, Regelsberger J, Westphal M, Schmidt NO. Impact of intraventricular hemorrhage measured by Graeb and LeRoux score on case fatality risk and chronic hydrocephalus in aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien). 2015 Mar;157(3):409-15. doi: 10.1007/s00701-014-2334-z. Epub 2015 Jan 21. PubMed PMID: 25599911.
4)

Bae IS, Yi HJ, Choi KS, Chun HJ. Comparison of Incidence and Risk Factors for Shunt-dependent Hydrocephalus in Aneurysmal Subarachnoid Hemorrhage Patients. J Cerebrovasc Endovasc Neurosurg. 2014 Jun;16(2):78-84. doi: 10.7461/jcen.2014.16.2.78. Epub 2014 Jun 30. PubMed PMID: 25045646; PubMed Central PMCID: PMC4102754.
5)

Sugawara T, Maehara T, Tadashi N, Aoyagi M, Ohno K. Independent predictors of shunt-dependent normal pressure hydrocephalus after aneurysmal subarachnoid hemorrhage. J Neurosurg Sci. 2014 Jul 29. [Epub ahead of print] PubMed PMID: 25069541.
6)

Zaidi HA, Montoure A, Elhadi A, Nakaji P, McDougall CG, Albuquerque FC, Spetzler RF, Zabramski JM. Long-term functional outcomes and predictors of shunt-dependent hydrocephalus after treatment of ruptured intracranial aneurysms in the BRAT trial: revisiting the clip vs coil debate. Neurosurgery. 2015 May;76(5):608-13; discussion 613-4; quiz 614. doi: 10.1227/NEU.0000000000000677. PubMed PMID: 25714521.
7)

Wang JY, Jackson EM, Jallo GI, Ahn ES. Shunt revision requirements after posthemorrhagic hydrocephalus of prematurity: insight into the time course of shunt dependency. Childs Nerv Syst. 2015 Nov;31(11):2123-30. doi: 10.1007/s00381-015-2865-5. Epub 2015 Aug 7. PubMed PMID: 26248674.
8)

Gerner ST, Kuramatsu JB, Abel H, Kloska SP, Lücking H, Eyüpoglu IY, Doerfler A, Schwab S, Huttner HB. Intraventricular fibrinolysis has no effects on shunt dependency and functional outcome in endovascular-treated aneurysmal SAH. Neurocrit Care. 2014 Dec;21(3):435-43. doi: 10.1007/s12028-014-9961-3. PubMed PMID: 24566979.
9)

Schmieder K, Koch R, Lücke S, Harders A. Factors influencing shunt dependency after aneurysmal subarachnoid haemorrhage. Zentralbl Neurochir. 1999;60(3):133-40. PubMed PMID: 10726336.
10)

Engel M, Carmel PW, Chutorian AM. Increased intraventricular pressure without ventriculomegaly in children with shunts: “normal volume” hydrocephalus. Neurosurgery. 1979 Nov;5(5):549-52. PubMed PMID: 534062.
11)

Epstein FJ, Hochwald GM, Wald A, Ransohoff J. Avoidance of shunt dependency in hydrocephalus. Dev Med Child Neurol Suppl. 1975;(35):71-7. PubMed PMID: 812752.
12)

Dong F, Wang Z, Li Y, Chen Z, Zhang S, Wan F. Shunt Dependency Syndrome after Cyst-Peritoneal Shunt Resolved by Keyhole Microsurgical Cyst Resection: Two Case Reports and Literature Review. Neuropediatrics. 2018 Jul 12. doi: 10.1055/s-0038-1661395. [Epub ahead of print] PubMed PMID: 30001565.
13)

Sonobe M, Kodama N, Fujiwara S, Takaku A, Suzuki J. [On-off mechanism of shunt system due to slit ventricle (author’s transl)]. No Shinkei Geka. 1978 Dec;6(12):1193-6. Japanese. PubMed PMID: 732936.

UpToDate: Retrograde VentriculoSinus Shunt

Retrograde VentriculoSinus Shunt

A retrograde ventriculosinus (RVS) shunt is a watertight connection that delivers excess cerebrospinal fluid(CSF) to the superior sagittal sinus (SSS) against the direction of blood flow. This method of CSF shunting utilizes the impact pressure (IP) of the bloodstream in the SSS to maintain the intraventricular pressure (IVP) more than the sinus pressure (SP) regardless of changes in posture or intrathoracic pressure (ITP) and discourages stagnation and clotting of blood at the venous end of the connection. It also utilizes collapse of the internal jugular vein (IJV) in the erect posture to prevent siphonage.

Since the 1950‘s, hydrocephalus can be treated with cerebrospinal fluid shunts, usually to the peritoneal cavityor to the right cardiac hearth atrium. However, due to their siphon effect, these shunts lead to non-physiological cerebrospinal fluid drainage, with possible co-morbidity and high revision rates. More sophisticated shunt valvesystems significantly increase costs and technical complexity and remain unsuccessful in a subgroup of patients. In an attempt to obtain physiological cerebrospinal fluid shunting, many neurosurgical pioneers shunted towards the dural sinuses, taking advantage of the physiological antisiphoning effect of the internal jugular veins. Despite several promising reports, the ventriculosinus shunts did not yet become standard neurosurgical practice.


50 RVS shunts were successfully implanted using valveless shunting catheters. There were no problems related to incorrect CSF drainage or sinus thrombosis. The results indicated arrest of the hydrocephalic process, normalization of the IVP and proper shunt function 1).

In 2016 Oliveira et al., published 3 consecutive cases who had previously undergone VPS revision and in which peritoneal space was full of adhesions and fibrosis. RVSS was performed as described by Shafei et al., with some modifications to each case. All 3 patients kept the same clinical profile after RVSS, with no perioperative or postoperative complications. However, revision surgery was performed in the first operative day in 1 out of 3 patients, in which the catheter was not positioned in the superior sagittal sinus. They propose that in cases where VPS is not feasible, RVSS may be a safe and applicable second option. Nevertheless, the long-term follow-up of patients and further learning curve must bring stronger evidence 2).


Baert et al., from the Department of Neurosurgery of Ghent University Hospital, Belgium implanted the retrograde ventriculosinus shunt, as advocated by El-Shafei, in 10 patients. They reports on the operation technique and long-term outcome, including 4 patients in whom this shunt was implanted as a rescue.

Implantation of a ventriculosinus shunt proved to be a feasible technique, warranting physiological drainage of cerebrospinal fluid. However, only in 3 out of 14 patients, functionality of the retrograde ventriculosinus shunt was maintained during more than 6 years follow-up. In there opinion, these shunts fail because present venous access devices are difficult to implant correctly and get too easily obstructed. After discussing possible causes of this frequent obstruction, a new dural venous sinus access device is presented.

An easy to implant and thrombogenic-resistant dural venous sinus access device needs to be developed before ventriculosinus shunting can become general practice 3).

1)

El-Shafei IL, El-Shafei HI. The retrograde ventriculosinus shunt: concept and technique for treatment of hydrocephalus by shunting the cerebrospinal fluid to the superior sagittal sinus against the direction of blood flow. Preliminary report. Childs Nerv Syst. 2001 Aug;17(8):457-65; discussion 466. PubMed PMID: 11508534.
2)

Oliveira MF, Teixeira MJ, Reis RC, Petitto CE, Gomes Pinto FC. Failed Ventriculoperitoneal Shunt: Is Retrograde Ventriculosinus Shunt a Reliable Option? World Neurosurg. 2016 Aug;92:445-453. doi: 10.1016/j.wneu.2016.05.038. Epub 2016 May 27. PubMed PMID: 27237416.
3)

Baert E, Dewaele F, Vandersteene J, Hallaert G, Okito Kalala JP, Roost DV. Treating Hydrocephalus with Retrograde VentriculoSinus Shunt Prospective Clinical Study. World Neurosurg. 2018 Jun 25. pii: S1878-8750(18)31313-5. doi: 10.1016/j.wneu.2018.06.097. [Epub ahead of print] PubMed PMID: 29953953.

Update: Cerebrospinal fluid shunt complication

see Lumboperitoneal shunt complication.
see Ventriculoperitoneal shunt complication.
Ventricular shunts for pediatric hydrocephalus continue to be plagued with high failure rates. Reported risk factors for shunt failure are inconsistent and controversial. The raw or global shunt revision rate has been the foundation of several proposed quality metrics.
The most common problems related to cerebrospinal fluid shunt are shunt obstruction, shunt infection and shunt overdrainage. The incidence of shunt complications is higher when less time has elapsed since the previous shunt surgery. Nearly all shunt patients end up with one or multiple reoperations. Thorough history, head scan (ultrasound, CT or MRI) and plain x-ray (shunt series) are the corner stones when reviewing shunt problems.
Wong et al. performed a PubMed search using search terms “cerebral shunt,” “cerebrospinal fluid shunt,” “CSF shunt,” “ventriculoperitoneal shunt,” “cerebral shunt AND complications,” “cerebrospinal fluid shunt AND complications,” “CSF shunt AND complications,” and “ventriculoperitoneal shunt AND complications.” Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the adverse events reported. RESULTS: In this review of the neurosurgery literature, the reported rate of mechanical malfunction ranged from 8% to 64%. The use of programmable valves has increased but remains of unproven benefit even in randomized trials. Infection was the second most common complication, with the rate ranging from 3% to 12% of shunt operations. A meta-analysis that included 17 randomized controlled trials of perioperative antibiotic prophylaxis demonstrated a decrease in shunt infection by half (OR 0.51, 95% CI 0.36-0.73). Similarly, use of detailed protocols including perioperative antibiotics, skin preparation, and limitation of OR personnel and operative time, among other steps, were shown in uncontrolled studies to decrease shunt infection by more than half. Other adverse events included intraabdominal complications, with a reported incidence of 1% to 24%, intracerebral hemorrhage, reported to occur in 4% of cases, and perioperative epilepsy, with a reported association with shunt procedures ranging from 20% to 32%. Potential management strategies are reported but are largely without formal evaluation.
Surgery for CSF shunt placement or revision is associated with a high complication risk due primarily to mechanical issues and infection. Concerted efforts aimed at large-scale monitoring of neurosurgical complications and consistent quality improvement within these highlighted realms may significantly improve patient outcomes 1).

Infection

Shunt dysfunction

Shunt overdrainage

see Shunt overdrainage.
Solid noninfectious growing mass
Shunt-related craniocerebral disproportion.
Slit ventricle syndrome and secondary craniosynostosis are late-onset complications after shunt placement these 2 conditions occasionally occur together.
see Tension pneumocephalus after shunt insertion.
The results of shunt testing are helpful in many circumstances, such as the initial choice of shunt and the evaluation of the shunt when its dysfunction is suspected 2).
Shunting procedures for syringomyelia have been criticized due to the inconsistent long-term outcomes.
This is largely the result of small volume flow at a very low-pressure profile leading to occlusion or malfunction of the shunts.

 Noises
Patients have reported anecdotally on noises associated with their shunts 4).

Diagnosis

Radionuclide shuntogram is important in the evaluation of cerebrospinal fluid shunt complications such as mechanical failure, malpositioning, pseudocyst, or overdrainage. Bermo et al present a case of congenital hydrocephalus and posterior fossa cyst with multiple shunt procedures and revisions with breakage of the proximal tube of the ventriculoperitoneal shunt but preserved CSF drainage through the patent fibrous tract. Careful correlation with SPECT/CT images helped confirm the breakage and exclude CSF leak outside of the tract, which was suspected on planar images 3).

Books

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Case series

2017

Kaestner et al. from the Department of Neurosurgery, Klinikum Kassel, Germany, identified all patients who had been treated or followed in our neurosurgical department within a 15-year period from January 2000 up to the end of 2014. After approval of the local ethics committee all patients who were cognitively intact were explored by a questionnaire and by personal interview about acoustic phenomena related to their shunts.
Three hundred forty-seven patients were eligible for the survey, and 260 patients completed the questionnaire. Twenty-nine patients (11.2%) reported on noises raised by their shunts. All of them experienced short-lasting noises while changing body posture, mainly from a horizontal to an upright position, or while reclining the head. Most of the patients reported on soft sounds, but loud and even very loud noises occurred in some patients. Seventy-six percent of the patients were not bothered by these noises as they considered it as a normal part of the therapy or as proof that the shunt device was functioning. Modern valves with gravitational units are prone to produce noises in young adults, but nearly all valve types can evoke noises.
Noises caused by a shunt do occur in a considerable number of patients with shunts. One should be aware of this phenomenon, and these patients must be taken seriously 5).

2016

Rossi et al undertook a study to determine risk factors for shunt revision within their own patient population.
In this single-center retrospective cohort study, a database was created of all ventricular shunt operations performed at the authors’ institution from January 1, 2010, through December 2013. For each index shunt surgery, demographic, clinical, and procedural variables were assembled. An “index surgery” was defined as implantation of a new shunt or the revision or augmentation of an existing shunt system. Bivariate analyses were first performed to evaluate individual effects of each independent variable on shunt failure at 90 days and at 180 days. A final multivariate model was chosen for each outcome by using a backward model selection approach.
There were 466 patients in the study accounting for 739 unique (“index”) operations, for an average of 1.59 procedures per patient. The median age for the cohort at the time of the first shunt surgery was 5 years (range 0-35.7 years), with 53.9% males. The 90- and 180-day shunt failure rates were 24.1% and 29.9%, respectively. The authors found no variable-demographic, clinical, or procedural-that predicted shunt failure within 90 or 180 days.
In this study, none of the risk factors that were examined were statistically significant in determining shunt failure within 90 or 180 days. Given the negative findings and the fact that all other risk factors for shunt failure that have been proposed in the literature thus far are beyond the control of the surgeon (i.e., nonmodifiable), the use of an institution’s or individual’s global shunt revision rate remains questionable and needs further evaluation before being accepted as a quality metric 6).

2015

A study aims to review the imaging findings of distal (thoracic and abdominal) complications related to ventriculo-peritoneal (VP), ventriculo-pleural (VPL), and ventriculo-atrial (VA) cerebrospinal fluid (CSF) shunt catheter placement. Institution review board-approved single-center study of patients with thoracic and abdominal CSF catheter-related complications on cross-sectional imaging examinations over a 14-year period was performed. Clinical presentation, patient demographics, prior medical history, and subsequent surgical treatment were recorded. The presence or absence of CSF catheter-related infection and/or acute hydrocephalus on cross-sectional imaging was also recorded. There were 81 distal CSF catheter-related complications identified on 47 thoracic or abdominal imaging examinations in 30 patients (age 5-80 years, mean 39.3 years), most often on CT (CT = 42, MRI = 1, US = 4). Complications included 38 intraperitoneal and 11 extraperitoneal fluid collections. Extraperitoneal collections included nine abdominal wall subcutaneous (SC) pseudocysts associated with shunt migration and obesity, an intrapleural pseudocyst, and a breast pseudocyst. There were also two large VPL-related pleural effusions, a fractured catheter in the SC tissues, and a large VA shunt thrombus within the right atrium. Ten patients (33.3 %) had culture-positive infection from CSF or shunt catheter samples. Ten patients (33.3 %) had features of temporally related acute or worsening hydrocephalus on neuroimaging. In four of these patients, the detection of thoracic and abdominal complications on CT preceded and predicted the findings of acute hydrocephalus on cranial imaging. Thoracic and abdominal complications of CSF shunts, as can be identified on CT, include shunt infection and/or obstruction, may be both multiple and recurrent, and may be predictive of concurrent acute intracranial problems 7).

2011

From January 1999 to December 2006, Korinek et al., conducted a prospective surveillance program for all neurosurgical procedures including reoperations and infections. Patients undergoing CSF shunt placement were retrospectively identified among patients labeled in the database as having a shunt as a primary or secondary intervention. Revisions of shunts implanted in another hospital or before the study period were excluded, as well as lumbo- or cyst-peritoneal shunts. Shunt complications were classified as mechanical dysfunction or infection. Follow-up was at least 2 years. Potential risk factors were evaluated using log-rank tests and stepwise Cox regression models.
During the 8-year surveillance period, a total of 14 275 patients underwent neurosurgical procedures, including 839 who underwent shunt placement. One hundred nineteen patients were excluded, leaving 720 study patients. Mechanical dysfunction occurred in 124 patients (17.2%) and shunt infection in 44 patients (6.1%). These 168 patients required 375 reoperations. Risk factors for mechanical dysfunction were atrial shunt, greater number of previous external ventriculostomies, and male sex; risk factors for shunt infection were previous CSF leak, previous revisions for dysfunction, surgical incision after 10 am, and longer operating time.
Shunt surgery still carries a high morbidity rate, with a mean of 2.2 reoperations per patient in 23.3% of patients. Our risk-factor data suggest methods for decreasing shunt-related morbidity, including peritoneal routing whenever possible and special attention to preventing CSF leaks after craniotomy or external ventriculostomy 8).

Case reports

James et al. describe 3 children who presented with progressively enlarging skin-covered solid masses over the shunt catheter in the neck/clavicular region. The authors reviewed the clinical, laboratory, pathological, radiographic, and follow-up data for all 3 patients and reviewed the literature on the subject. The patients had no clinical evidence of an infectious process. Surgical exploration revealed that masses were surrounding and encasing the shunt tubing to which they were strongly attached. Pathological studies of the tissues demonstrated varying degrees of exuberant chronically inflamed granulation tissues, interstitial fibrosis, and dystrophic calcification. One patient had associated thinning of the skin overlying the mass and subsequently developed ulceration. No infectious organisms were observed. The cerebrospinal fluid aspirates from the shunts did not yield any organisms. There has been no recurrence of the masses. The presence of a growing mass over the shunt tube in the neck or the chest region without clinical evidence of infection does not indicate that the mass should be treated with antibiotics and complete shunt removal. Rather, the mass can be cured by extirpation and with “bypass” new shunt tubing locally 9).
1)

Wong JM, Ziewacz JE, Ho AL, Panchmatia JR, Bader AM, Garton HJ, Laws ER, Gawande AA. Patterns in neurosurgical adverse events: cerebrospinal fluid shunt surgery. Neurosurg Focus. 2012 Nov;33(5):E13. doi: 10.3171/2012.7.FOCUS12179. Review. PubMed PMID: 23116093.
2)

Chari A, Czosnyka M, Richards HK, Pickard JD, Czosnyka ZH. Hydrocephalus shunt technology: 20 years of experience from the Cambridge Shunt Evaluation Laboratory. J Neurosurg. 2014 Jan 3. [Epub ahead of print] PubMed PMID: 24405071.
3)

Bermo M, Leung AS, Matesan M. A Case of Discontinued Proximal Limb of a Ventriculoperitoneal Shunt With Patent Fibrous Tract. Clin Nucl Med. 2016 Feb 24. [Epub ahead of print] PubMed PMID: 26914568.
4)

Kaestner S, Fraij A, Deinsberger W, Roth C. I can hear my shunt-audible noises associated with CSF shunts in hydrocephalic patients. Acta Neurochir (Wien). 2017 Apr 14. doi: 10.1007/s00701-017-3179-z. [Epub ahead of print] PubMed PMID: 28411322.
5)

Kaestner S, Fraij A, Deinsberger W, Roth C. I can hear my shunt-audible noises associated with CSF shunts in hydrocephalic patients. Acta Neurochir (Wien). 2017 Jun;159(6):981-986. doi: 10.1007/s00701-017-3179-z. Epub 2017 Apr 14. PubMed PMID: 28411322.
6)

Rossi NB, Khan NR, Jones TL, Lepard J, McAbee JH, Klimo P Jr. Predicting shunt failure in children: should the global shunt revision rate be a quality measure? J Neurosurg Pediatr. 2016 Mar;17(3):249-59. doi: 10.3171/2015.5.PEDS15118. Epub 2015 Nov 6. PubMed PMID: 26544083.
7)

Bolster F, Fardanesh R, Morgan T, Katz DS, Daly B. Cross-sectional imaging of thoracic and abdominal complications of cerebrospinal fluid shunt catheters. Emerg Radiol. 2015 Nov 26. [Epub ahead of print] PubMed PMID: 26610766.
8)

Korinek AM, Fulla-Oller L, Boch AL, Golmard JL, Hadiji B, Puybasset L. Morbidity of ventricular cerebrospinal fluid shunt surgery in adults: an 8-year study. Neurosurgery. 2011 Apr;68(4):985-94; discussion 994-5. doi: 10.1227/NEU.0b013e318208f360. PubMed PMID: 21221037.
9)

James HE, Postlethwait RA, Sandler ED. Solid noninfectious growing masses over cerebrospinal fluid shunts: report of 3 cases. J Neurosurg Pediatr. 2015 Jan 30:1-4. [Epub ahead of print] PubMed PMID: 25634820.

Shunt implantations and peritoneal catheters: Do not cut beyond 20 cm

Ventriculoperitoneal shunts are supplied with long peritoneal catheters, most commonly between 80 and 120 cm long. ISO/DIS 7197/2006([15]) shunt manufacturing procedures include peritoneal catheter as an integrate of the total resistance. Cutting pieces of peritoneal catheters upon shunt implantation or revision is a common procedure.

METHODS:

We evaluated five shunts assembled with different total pressure resistances and variable peritoneal catheter lengths in order to clarify the changes that occurred in the hydrodynamic profile when peritoneal catheters were cut upon shunt implantation or shunt revision.

RESULTS:

Originally, all shunts performed within the operational range. Shunt 1 performed in a lower pressure range at 200 mm cut off peritoneal catheter and as a low-pressure shunt with -300 mm cut off. Shunt 2 was manufactured to run at the higher border pressure range, and it went out of specification with a 300 mm cut off. Shunt 3 was manufactured to run close to the lower border pressure range, and at 100 mm cutoff, it was already borderline in a lower resistive category. Other shunts also responded similarly.

CONCLUSION:

The limit to maintain a shunt in its original pressure settings was 20 cm peritoneal catheter cutting length. By cutting longer pieces of peritoneal catheter, one would submit patients to a less-resistive regimen than intended and his reasoning will be compromised. The pediatric population is more prone to suffer from the consequences of cutting catheters. Shunt manufacturers should consider adopting peritoneal catheters according to the age (height) of the patient.
Maset AL, Suriano LC, Monteiro R, Pinto JR, de Andrade JR, Mancini BM, Ramin SL, Moraes DF, Cavalheiro S. Shunt implantations and peritoneal catheters: Do not cut beyond 20 cm. Surg Neurol Int. 2014 Aug 22;5:130. doi: 10.4103/2152-7806.139410. eCollection 2014. PubMed PMID: 25250184.

Update: Subdural hematoma after lumboperitoneal shunt

Subdural hematoma after lumboperitoneal shunt

J.Sales-Llopis
Neurosurgery Department, University General Hospital of Alicante, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Alicante, Spain

Subdural hematoma can be a serious lumboperitoneal shunt complication.
Physicians should be aware of this potentially devastating complication of shunt placement 1).
Castillo et al. alert about the need to take into account subarachnoid hemorrhage and venous sinus thrombosis as possible complications in the followup of these patients 2).
A 67-year-old man suffered from persistent headache worsening with postural change 2 months after LP shunt reconstruction for iNPH. Head computed tomography showed bilateral chronic subdural hematomas (CSDH). Lumbar images including shuntography and magnetic resonance imaging showed the tip of the lumbar catheter was spontaneously pulled out close to the dura mater with expansion of the epidural space due to Cerebrospinal fluid leakage from a shunt side hole of the lumbar catheter to the epidural space. Shunt removal and subsequent irrigation of CSDH improved his headache. CSF leakage in this case differs from those in previous reports, because early and enormous CSF leakage into the epidural space can be explained only by a different mechanism through a side hole just located in the epidural space in this case. We must pay attention to the possibility of this rare cause of IH due to CSF leakage in patients suffering from postural headache after LP shunt placement 3).

Mild traumatic brain injury

Patients with lumboperitoneal shunts, especially those not capable of independent daily activities, are at risk for acute subdural hematoma after even mild traumatic brain injury 4).
Aoki et al. report four patients treated with a lumboperitoneal shunt in whom acute subdural hematoma occurred after minor head trauma. Three of the four patients had subdural fluid collection or widening of subarachnoid space observed on computed tomography scan after placement of the lumboperitoneal shunt, and discuss its mechanism 5).

1) Barash IA, Medak AJ. Bilateral subdural hematomas after lumboperitoneal shunt placement. J Emerg Med. 2013 Aug;45(2):178-81. doi: 10.1016/j.jemermed.2013.01.030. Epub 2013 Apr 30. PubMed PMID: 23643242.
2) Castillo L, Bermejo PE, Zabala JA. [Unusual complications of the lumboperitoneal shunt as treatment of benign intracranial hypertension]. Neurologia. 2008 Apr;23(3):192-6. Spanish. PubMed PMID: 18370342.
3) Matsubara T, Ishikawa E, Hirata K, Matsuda M, Akutsu H, Masumoto T, Zaboronok A, Matsumura A. A new mechanism of cerebrospinal fluid leakage after lumboperitoneal shunt: a theory of shunt side hole–case report. Neurol Med Chir (Tokyo). 2014;54(7):572-7. Epub 2013 Dec 5. PubMed PMID: 24305015; PubMed Central PMCID: PMC4533463.
4) Kamiryo T, Hamada J, Fuwa I, Ushio Y. Acute subdural hematoma after lumboperitoneal shunt placement in patients with normal pressure hydrocephalus. Neurol Med Chir (Tokyo). 2003 Apr;43(4):197-200. PubMed PMID: 12760499.
5) Aoki N, Mizutani H. Acute subdural hematoma due to minor head trauma in patients with a lumboperitoneal shunt. Surg Neurol. 1988 Jan;29(1):22-6. PubMed PMID: 3336835.

Top Read: Ventriculocisternostomy versus ventriculoperitoneal shunt in the treatment of hydrocephalus: A retrospective, long-term observational study.

Clin Neurol Neurosurg. 2014 Jul;122:92-6. doi: 10.1016/j.clineuro.2014.03.022. Epub 2014 Mar 26.

Ventriculocisternostomy versus ventriculoperitoneal shunt in the treatment of hydrocephalus: A retrospective, long-term observational study.

Abstract

OBJECTIVE:

The goal of this study was the retrospective analysis of long-term data on endoscopic ventriculocisternostomy versus ventriculoperitoneal shunt placement in the treatment of hydrocephalus.

METHODS:

A total of 159 patients were included in the study. One hundred and twenty-three patients received a ventriculoperitoneal shunt, whereas 36 patients were treated with an endoscopic procedure. Only patients with a postoperative observation period of at least 3 years were included in the analyses of the long-term data. In addition to general patient and operation data, the number and frequency of perioperative complications (infections, dysfunctions) and the frequency and type of necessary revision operations were collected.

RESULTS:

The average observation period was 69 months for both groups. The risk of operative revision was significantly elevated in the shunt group despite a comparable observation period. Whereas 86.11% of the endoscopy group did not require an operative revision, that only applied to 68.85% of the shunt group. The complication rate was 42.7% in the shunt group per procedure, which was clearly higher than in the endoscopy group at only 9.4%.

CONCLUSION:

The risk of operative revision and/or complications is significantly lower in the endoscopic ventriculocisternostomy group compared to the ventriculoperitoneal shunt group. Given the appropriate indication, endoscopic ventriculocisternostomy is thus the treatment of choice.

Resultados del Cambridge Shunt Evaluation Laboratory

Tipos de válvula programables

Codman Hakim
Strata
Miethke
Polaris
CERTAS
ProGAV
Los ajustes pueden ser influenciados por campos magnéticos externos de intensidad por encima de 40 mT excepto las proGAV, Polaris, y CERTAS ((Chari A, Czosnyka M, Richards HK, Pickard JD, Czosnyka ZH. Hydrocephalus shunt technology: 20 years of experience from the Cambridge Shunt Evaluation Laboratory. J Neurosurg. 2014 Jan 3. [Epub ahead of print] PubMed PMID: 24405071.))
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