Intraabdominal complications secondary to ventriculoperitoneal shunts: CT findings and review of the literature.

Chung JJ, Yu JS, Kim JH, Nam SJ, Kim MJ. (2009) Intraabdominal complications secondary to ventriculoperitoneal shunts: CT findings and review of the literature.
AJR American Journal of Roentgenology. 2009 Nov;193(5):1311-7. Review.

OBJECTIVE: The purpose of our study was to evaluate the abdominopelvic CT findings of various intraabdominal complications secondary to ventriculoperitoneal shunts for hydrocephalus and to review the literature.

MATERIALS AND METHODS: The CT images of 70 patients (33 men and 37 women; mean age, 48.5 years) who underwent ventriculoperitoneal shunt placement and abdominopelvic CT because of shunt-related abdominal symptoms were reviewed retrospectively. CT images were analyzed with regard to the location of the shunting catheter tip; site, size, wall, and septa of localized fluid collection; peritoneal thickening; omentomesentery infiltration; abscess; bowel perforation; abdominal wall infiltration; and thickening of the catheter track wall.

RESULTS: The mean period between the last ventriculoperitoneal shunting operation and CT was 11 months (range, 1 week to 115 months), and the mean number of ventriculoperitoneal shunting operations undergone was 1.4 (range, 1-6). A total of 76 ventriculoperitoneal shunting catheters were introduced in 70 patients: 64 patients had a unilateral catheter inserted and six patients had bilateral catheters inserted. Sixteen patients (22.9%) were pathologically diagnosed with ventriculoperitoneal shunt-related complications: 11 cases (15.7%) of shunt infection, six cases (8.6%) of CSF pseudocyst, four cases (5.7%) of abdominal abscess, three cases (4.3%) of infected fluid collection, and one case (1.4%) of bowel perforation. Microorganisms were cultured from the tip of the shunting catheter or peritoneal fluid in 11 patients (15.7%).

CONCLUSION: On abdominopelvic CT, various intraabdominal complications secondary to ventriculoperitoneal shunt were shown, of which, shunt infection was the most common, followed by CSF pseudocyst, abscess, and infected fluid collection.

PMID: 19843747

Shunt complications in children with myelomeningocele: effect of timing of shunt placement. Clinical article.

Radmanesh F, Nejat F, El Khashab M, Ghodsi SM, Ardebili HE. (2009) Shunt complications in children with myelomeningocele: effect of timing of shunt placement. Clinical article. Journal of Neurosurgery: Pediatrics. 2009 Jun;3(6):516-20.

Department of Neurosurgery, Children's Hospital Medical Center, and Department of Biostatistics, Tehran University of Medical Sciences, Tehran, Iran.

OBJECT There has been controversy over whether CSF shunt insertion simultaneously with repair of myelomeningocele (MMC) might increase shunt-related complications. The purpose of this study was to evaluate shunt complication rates in patients who underwent concurrent MMC surgery and shunt placement and compare them to the rates in patients treated with shunt placement in a separate procedure.

METHODS The authors retrospectively reviewed the outcome of shunt placement in 127 patients with MMC who were followed up for >or=1 year after shunt surgery. In 65 patients shunt surgery was performed in a second operation after MMC repair and in 46 the 2 procedures were performed concurrently. In 7 patients shunt placement was the initial surgery, and in 9 it was the only procedure performed. The patients were evaluated for shunt complications.

RESULTS There was no statistically significant between-groups difference in age at which patients underwent shunt placement. The overall rates of shunt infection and shunt malfunction were 16.5 and 39.4%, respectively. There was a high rate of shunt infection and mortality in those patients treated with CSF shunting only. There was no statistically significant difference between complication rates in patients in whom the 2 procedures were performed concurrently and those who underwent separate operations.

CONCLUSIONS The order in which myelomeningocele repair and shunt placement were carried out did not have a significant effect on the rate of shunt complications. Thus, when indicated these procedures can be performed concurrently with a level of risk comparable to that associated with delayed shunt placement.

PMID: 19485738

Early shunt complications in 46 children with hydrocephalus.

Braga MH, Carvalho GT, Brandão RA, Lima FB, Costa BS. (2009) Early shunt complications in 46 children with hydrocephalus. Arquivos de neuro-psiquiatria. 2009 Jun;67(2A):273-7.

Department of Neurosurgery, Santa Casa de Belo Horizonte, MG, Brazil.

OBJECTIVE: To determine the causes of early shunt complications in 46 children with hydrocephalus. METHOD: A retrospective study was conducted on 46 children submitted to ventriculoperitoneal shunt surgery between February 2005 and February 2007. RESULTS: Thirteen (28%) patients presented complications, which were due to infection in 9 (69%) and to malfunction of the shunt system in 4 (31%).The mean number of surgical procedures performed on patients who presented complications was 2.8 per patient, with a total of 46 surgeries in this group. All patients with infectious complications were identified during their hospital stay. CONCLUSIONS: Infection was the most common complication. The infection rate was proportional to the length of hospital stay. All patients with hydrocephalus due to tumors or myelomeningocele presented complications. A higher incidence of infections was observed in children older than 2 years.

PMID: 19547822

Intradural inclusion cysts following in utero closure of myelomeningocele: clinical implications and follow-up findings.

Danzer E, Adzick NS, Rintoul NE, Zarnow DM, Schwartz ES, Melchionni J, Ernst LM, Flake AW, Sutton LN, Johnson MP. (2008) Intradural inclusion cysts following in utero closure of myelomeningocele: clinical implications and follow-up findings.
Journal of Neurosurgery: Pediatrics. 2008 Dec;2(6):406-13.

The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia; and The University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.

OBJECT: The goal in this study was to evaluate the incidence and clinical implications of the development of cutaneously derived intradural inclusion cysts (ICs) following fetal myelomeningocele (fMMC) closure.

METHODS: Retrospective databases and responses to a parental questionnaire were reviewed to determine the incidence, clinical presentation, and outcomes of fMMCs in children in whom ICs developed at follow-up.

RESULTS: Prior to the National Institutes of Health (NIH)-sponsored Management of Myelomeningocele Study (MOMS), 54 patients underwent fMMC closure at the authors' institution. Sixteen (30%) presented with symptomatic tethered cord syndrome (TCS) at a median age of 27 months (range 4-93 months). Ten (63%) of the 16 (19% of the total) developed TCS in association with an intradural IC. In 9 (90%) of 10 patients, the IC was seen on preoperative MR imaging, and in 1 it was found during surgery. Four additional children (7% of the total) with evidence of an IC on surveillance MR imaging are currently asymptomatic at 94, 84, 60, and 60 months of age, respectively. All but 1 (an L-3 level lesion) IC developed in infants with L-4 and L-5 defects. After cyst removal, 6 children are asymptomatic at a median follow-up of 36 months (range 12-63 months). Following IC removal, 4 children lost normal bladder function and now require clean intermittent catheterization, and 1 lost normal leg function and now requires a walking aid for ambulation. Histologically, 8 lesions were dermoid, 1 was an epidermoid, and 1 was a mixed dermoid-epidermoid IC. Three patients developed another IC and required its removal at 24, 39, and 51 months, respectively. One required another tethered cord release within 57 months after IC removal.

CONCLUSIONS: Cutaneously derived intradural ICs can develop following fMMC surgery. Deterioration of bladder function, risk of recurrence, and loss of lower-extremity function appear to be the most important long-term complications of IC in children with fMMCs. The ongoing NIH-sponsored MOMS may help determine whether children with fMMC are at increased risk of IC development compared with children treated with postnatal MMC closure. Parents seeking fMMC closure should be informed about the possibility of IC formation and the potential clinical consequences.

PMID: 19035686

Tethered cord release: a long-term study in 114 patients.

Bowman RM, Mohan A, Ito J, Seibly JM, McLone DG. (2009) Tethered cord release: a long-term study in 114 patients. Journal of Neurosurgery Pediatrics. 2009 Mar;3(3):181-7.

Division of Pediatric Neurosurgery, Children's Memorial Hospital, Chicago, USA. rbowman@childrensmemorial.org

OBJECT: All children born with a myelomeningocele at the authors' institution undergo aggressive treatment to maintain or improve functional outcome. Consequently, when any neurological, orthopedic, and/or urological changes are noted, a search for the cause is initiated. The most common cause of decline in a child born with a myelomeningocele is shunt malfunction. The second most common cause is tethering of the distal spinal cord at the site of the original back closure. In this report, the authors review the indicators of symptomatic spinal cord tethering and discuss the surgical interventions and outcomes in the children with myelomeningocele who underwent treatment at Children's Memorial Hospital from 1975 to 2008.

METHODS: Among the 502 children who underwent original closure at Children's Memorial Hospital, a symptomatic tethered spinal cord developed in 114 (23%). Eighty-one patients (71%) have undergone 1 untethering procedure, and 33 patients (29%) have undergone multiple untetherings, for a total of 163 total surgeries. The indicators of symptomatic spinal cord tethering include scoliosis, decline in lower-extremity (LE) motor strength, LE contractures, LE spasticity, gait change, urinary changes, and pain.

RESULTS: Pain has shown the best response to surgical untethering, with 100% of children experiencing postoperative improvement. The results of long-term follow-up (average 12 years, range 1 month-23.3 years) in this cohort demonstrated scoliosis progression after surgical untethering in 52% of patients, with 28% requiring spinal fusion. On the 3-month postoperative manual muscle test, 70% of patients showed improved LE muscle strength compared to preoperatively. Gait was also similarly improved after untethering as evaluated by an orthopedic surgeon. Spasticity improved in two-thirds of the cohort, and as expected, LE contractures were stable (78%) postoperatively, as assessed by orthopedic and rehabilitation medicine specialists. Urologically, 64% of patients showed improvements on postoperative bladder evaluation.

CONCLUSIONS: Although this is a clinical outcome study with no control group, the authors' experience has been that tethered cord release is beneficial in maintaining neurological, urological, and orthopedic functioning in children born with a myelomeningocele.

PMID: 19338463

Complications with shunts in adults with spina bifida

Tomlinson P, Sugarman ID. Complications with shunts in adults with spina bifida. British Medical Journal 1995 Jul 29;311(7000):286-7.

OBJECTIVE--To assess the incidence of malfunction of shunts in adults with spina bifida who have shunts to control hydrocephalus.

DESIGN--A retrospective review of the medical notes and contact by questionnaire of adults with spina bifida to assess symptoms, function of shunts, frequency of operative procedures, and follow-up.

SUBJECTS--110 patients with shunts who attended Lord Mayor Treloar College for the physically disabled between 1978 and 1993.

RESULTS--The average (range) number of revisions of shunts per person was 3.6 (0-28). Although 37 patients underwent an emergency operation for revision in their first year of life, there was a continuing low incidence, increasing in the early teenage years, which persisted into the third decade. Intervals between emergency revisions varied: 202/320 occurred within one year of the last shunt operation, 56 occurred after five years, 24 after 10 years, and 15 after 15 or more years. Fifteen patients had chronic intermittent headaches, of whom four died and three suffered severe morbidity. Thirteen died; three had raised intracranial pressure, and four died suddenly; these deaths were presumed to be related to their shunts. Up to the age of 16 there was 100% hospital follow up, but after that only 40% of young adults underwent review, including review of their shunt function.

CONCLUSION--Shunts to control hydrocephalus may fail after many years without symptoms. This is difficult to diagnose and if missed may lead to chronic morbidity and death. As hospital follow up of this group is falling, both general practitioners and hospital doctors must be aware that a shunt may malfunction after prolonged quiescent periods.

PMID: 7633231

Why do adults with spina bifida and hydrocephalus die?

McDonnell GV, McCann JP. Why do adults with spina bifida and hydrocephalus die? A clinic-based study. European Journal of Pediatric Surgery. 2000 Dec;10 Suppl 1:31-2.

AIM: To establish the death rate and factors contributing to death among attenders at a clinic for adults with spina bifida and hydrocephalus (CASBAH).

INTRODUCTION: Due to improvements in medical care in the past 40 years, increasing numbers of spina bifida patients go on to prosper in adult life. Despite this, levels of morbidity are high and services for such patients are uneven and unpredictable.

MATERIALS AND METHODS: Since 1990 there has been a CASBAH service in Belfast operating on a regional basis. Led by a consultant in rehabilitation medicine, it provides a multidisciplinary approach to patient care. Between 1990 and 1999 there have been 280 referrals to the clinic. Charts were reviewed regarding current health status and mode of death where relevant.

RESULTS: There have been 18 deaths during the term of the clinic (6.4%). There were four deaths due to renal failure and two due to cardiac failure. Two deaths occurred following surgery for a Chiari/hydrosyringomyelia complex and one patient died due to shunt malfunction. Three deaths were presumed related to infection. Two deaths were attributable to malignancy (carcinoma of a renal conduit and transitional cell carcinoma of the kidney) and other terminal events in one patient each were: basilar artery aneurysm rupture, post-partum pulmonary embolism, peptic ulcer disease, myocardial infarction and status epilepticus.

CONCLUSIONS: Although certain deaths were unpredictable during the period of review and not directly attributable to spina bifida, the majority reflect many of the related secondary health issues of the condition and indicate the need for organised, medically co-ordinated follow-up of adult patients.

PMID: 11214829

Do grip and pinch strength predict neurologic complications in children with spina bifida and hydrocephalus

Liptak GS, Fried R, Baltus-Hebert E, Eyer Tierney S, Fucile S, Doremus TL. Do grip and pinch strength predict neurologic complications in children with spina bifida and hydrocephalus? Pediatric Neurosurgery. 2006;42(4):208-13.

BACKGROUND: Neurological complications occur commonly in children with meningomyelocele and can cause significant morbidity and mortality. An earlier study suggested that acute changes in grip and pinch strength could be used to identify individuals at increased risk for developing a neurological complication.

OBJECTIVE: To evaluate the use of grip and pinch measurements to screen for neurological problems in children with spina bifida and hydrocephalus.

DESIGN: A prospective evaluation of screening tests.

PATIENTS: 92 children, born since 1976, who had meningomyelocele and hydrocephalus and were treated at the University of Rochester Medical Center.

METHODS: Grip and pinch strength were measured between July, 1991, and June, 2003. RESULTS: Mean grip and pinch strengths were similar to those found in previous studies of children with meningomyelocele; 58 neurological events occurred in 39 (40%) individuals. These included 31 episodes of ventricular shunt failure and 22 symptomatic tethered cord occurrences. Specificity, sensitivity and likelihood ratios were calculated in multiple ways using different criteria for loss of grip or pinch strength and for interval to neurological event. Sensitivities were low (<0.35) and the highest positive likelihood ratio found, using fall in either lateral pinch with 6 months to neurological event, was 2.3.

CONCLUSIONS: Despite previous recommendations, grip and pinch measurements were not helpful when used as a routine screening test for neurological dysfunction for children with meningomyelocele and hydrocephalus.

PMID: 16714860

Lessons learned from stomal complications in children with cutaneous catheterizable continent stomas

Barqawi A, de Valdenebro M, Furness PD 3rd, Koyle MA. Lessons learned from stomal complications in children with cutaneous catheterizable continent stomas.
BJU International. 2004 Dec;94(9):1344-7.

OBJECTIVE: To evaluate the impact of various factors that might ultimately influence the stoma complication rate associated with the construction of a continent catheterizable urinary (CCU) and Malone antegrade colonic enema (MACE) stoma in children.

PATIENTS AND METHODS: Retrospectively, we reviewed our experience in patients who had a CCU and/or MACE stoma reconstructed at our institution from 1992 to 2003. Diagnosis, type of stoma constructed (CCU vs MACE), single vs dual stomas, stomal site, conduit material (appendix, split appendix, Monti-Yang or ureter), sex, age, patient mobility and body mass index, race and concomitant surgery (e.g. bladder augmentation with or without bladder neck reconstruction) were evaluated for stoma-related complications. In all, 109 patients (64 males and 45 female), with a mean (sd, range) age of 8.6 (5.7, 2-37) years, had 151 stomas constructed during the period of analysis, comprising 56 CCU only, 11 MACE only and 42 (84 stomas) both simultaneously.

RESULTS: The mean (range) follow-up was 48 (6-144) months. The primary diagnoses were neurogenic bladder in 60 (55%), bladder exstrophy/epispadias in 17 (16%) and posterior urethral valves in 11 (9%) patients. The umbilicus was the primary site for the CCU stoma in 88 of 98 (90%) cases, while the right lower quadrant was the primary site for MACE in 46 of 53 (87%). After surgery complete stomal continence was provided in 95 of 98 (97%) CCU stoma, whereas the MACE was successful in 52 of 53 (99%). The stoma-related complications included stenosis in 27, leakage in eight, false passage in four, atrophy in two, keloid in one, and breakdown of the stoma in two. Individually, only greater age and a primary diagnosis of neurogenic bladder were independent risk factors associated with an increased rate of stomal complications and higher incidence of revision (P < 0.05).

CONCLUSION: Stomal complications are extremely common whether CCU or MACE stomas are constructed individually or together. Nevertheless, despite the need for revision, the high stoma continence rate supports their use. Greater age at surgery and a primary diagnosis of neurogenic bladder were associated with a significant increase in the stoma-related complications and the need for revision.

PMID: 15610118

Continent catheterizable channels and the timing of their complications

Thomas JC, Dietrich MS, Trusler L, DeMarco RT, Pope JC 4th, Brock JW 3rd, Adams MC. Continent catheterizable channels and the timing of their complications. Journal of Urology. 2006 Oct;176(4 Pt 2):1816-20; discussion 1820.

PURPOSE: We reviewed our experience with continent catheterizable channels with interest in the timing of conduit related complications.

MATERIALS AND METHODS: A retrospective review was performed of the outcome of continent catheterizable channels in all patients between 1998 and 2003 who had undergone construction of an antegrade continence enema and/or a Mitrofanoff procedure using appendix, small bowel or continent cutaneous vesicostomy. We performed a total of 117 such stomas in 37 male and 41 female patients 2.5 to 20 years old (mean age 8.9). For the antegrade continence enema we used appendix in 92% of cases, an ileal Yang-Monti tube in 6% and a cecal tube in 2%. For the continent catheterizable channel we used appendix in 43% of cases, a Yang-Monti tube in 38% and continent cutaneous vesicostomy in 19%.

RESULTS: Continence was achieved in 98% of patients. Followup was 6 to 71 months (mean 28.4). There were 27 channel related complications (23%). Stomal stenosis occurred in 7 antegrade continence enema procedures (14%) within 1 to 10 months (mean 6.2) and in 9 continent bladder channels (13%), including 5 continent cutaneous vesicostomies, within 1 to 24 months (mean 9.4) after surgery. False passages occurred in 5 antegrade continence enema procedures (10%) within 1 to 13 months (mean 3.6) and in 4 continent catheterizable channels (6%) within 1 to 13 months (mean 6.5) after surgery. Of patients with stomal stenosis 50% were treated with surgical revision, while the remainder was successfully treated with dilation. Most false passages were managed by catheter drainage alone. Reasons for revision were contained perforation, colovesical fistula and inability to catheterize. Patient noncompliance appeared to have a role in stomal stenosis.

CONCLUSIONS: Continent catheterizable stomas help patients achieve bowel and bladder continence. Stomal incontinence after reconstruction is rare. In our experience most stoma related complications occurred in the first year after reconstruction. Experience with more patients and longer followup will help determine whether such problems continue to accumulate with time or whether continent stomas function well with time, particularly after the initial period of healing.

PMID: 16945657

Referred shoulder pain from ventriculoperitoneal shunts. Report of three cases.

Tubbs RS, Wellons JC 3rd, Blount JP, Grabb PA, Oakes WJ. Referred shoulder pain from ventriculoperitoneal shunts. Report of three cases. Journal of Neurosurgery. 2005 Mar;102(2 Suppl):218-20.

The authors report on three pediatric patients with ventriculoperitoneal (VP) shunts who presented with chronic right shoulder pain. Imaging revealed that the distal peritoneal catheter was positioned between the right hemidiaphragm and liver. Following surgical repositioning of the distal tubing, all patients experienced resolution of their shoulder pain, which has not recurred. Although seemingly rare, referred shoulder pain from a VP shunt should be added to the list of complications seen with this method of cerebrospinal fluid diversion. The clinician who cares for patients with VP shunts may wish to evaluate cases of shoulder pain without obvious neural or musculoskeletal cause by performing imaging of the distal shunt tubing.

PMID: 16156233

Complications and pitfalls of neuroendoscopic surgery in children.

Peretta P, Ragazzi P, Galarza M, Genitori L, Giordano F, Mussa F, Cinalli G. Complications and pitfalls of neuroendoscopic surgery in children. Journal of Neurosurgery. 2006 Sep;105(3 Suppl):187-93.

OBJECT: Neuroendoscopic surgery is being used as an alternative to traditional shunt surgery and craniotomy in the management of hydrocephalus and intracranial fluid-filled cavities. In this study, the authors evaluated the incidence and type of complications occurring after neuroendoscopic procedures that were performed in a consecutive series of pediatric patients at a single institution to determine the effectiveness of neuroendoscopy in such patients.

METHODS: Four hundred ninety-five neuroendoscopic procedures were consecutively performed in 450 pediatric patients at one institution over a 10-year period. Charts were retrospectively reviewed. A complication was defined as follows: 1) any postoperative neurological deficit that was not observed before surgery; 2) any event occurring during surgery that resulted in the procedure being aborted; or 3) any adverse event occurring within 7 days postsurgery that resulted in a modification of the normal postoperative care. However, headache, vomiting, and fever without cerebrospinal fluid (CSF) pleocytosis were not considered complications. Complications were observed in 40 (8.1%) of 495 procedures. Two patients had two complications. One patient died of diffuse brain edema following endoscopic biopsy sampling of a basal ganglia tumor (mortality rate 0.2%). Other complications observed were abandonment of the procedure in eight cases, CSF leakage in 11 (with associated wound infection in one), intraventricular hemorrhage in six (with external drainage needed in four), intraparenchymal hemorrhage in three, subdural collection in eight (with subdural-peritoneal shunt placement needed in seven), transient oculomotor palsy in two, and transient hemiparesis in one.

CONCLUSIONS: Many complications can be avoided by determining the correct diagnosis and using suitable techniques and instruments. Most complications can be managed conservatively and do not produce long-term morbidity. Complex procedures in most patients and simple procedures in patients with preoperative risk factors carry the highest hazard. Every attempt should be made to optimize the surgical technique. The most serious and potentially the most lethal complication remains arterial bleeding from injury to the basilar artery complex.

PMID: 16970231

Evaluation and management of shunt infections in children with hydrocephalus.

Duhaime AC. Evaluation and management of shunt infections in children with hydrocephalus. Clinical Pediatrics 2006 Oct;45(8):705-13.

Shunt infections constitute one of the main risks of shunt surgery for hydrocephalus, which is the single most common type of surgery performed by pediatric neurosurgeons. Infectious complications are responsible for increased morbidity and mortality, lengthy hospitalizations, and high cost. Most modern series report infection rates approaching 10% of all shunt procedures. Despite the high incidence of this complication, optimal management is still unknown, and research on prevention has been hampered by single-institution series and small numbers. This article will review the history, causes, presentation, management, and outcome from shunt infections in children. Pitfalls in diagnosis and management will be reviewed. Finally, prevention strategies and research questions still remaining in this area will be outlined.

PMID: 16968955

Shunt infection: is there a near-miss scenario?

Thompson DN, Hartley JC, Hayward RD. Shunt infection: is there a near-miss scenario? Journal of Neurosurgery. 2007 Jan;106(1 Suppl):15-9.

OBJECT: The aim of this study was to establish whether microbiological contamination at the time of shunt insertion can be detected and used to predict the likelihood of subsequent shunt infection.

METHODS: A prospective study of pediatric patients undergoing primary shunt insertion was undertaken. Following the protocol devised for this study, three swab samples were collected from the surgical wounds during each procedure. These samples were incubated and subcultured, and the isolates were identified and stored. In patients who subsequently presented with clinical evidence of shunt infection, cerebrospinal fluid (CSF) was analyzed using microscopy, tissue cultures, and sensitivity testing. The organisms isolated at the time of shunt insertion and those responsible for subsequent shunt infection were then compared. The study population consisted of 107 pediatric patients. Because one patient underwent placement of an additional contralateral shunt system, there were 108 total shunt insertions yielding 325 swab samples. Organisms were identified in cultures of 50 swab samples (15%) obtained in 40 patients (37%). In seven of these 40 patients (17.5%) a CSF infection subsequently developed. In only one patient was the infectious organism the same as that isolated from the swab specimens. In an additional six patients (8.8%) a CSF infection occurred despite the lack of growth in the cultures from intraoperative swab samples.

CONCLUSIONS: The organisms responsible for shunt infection were rarely detected in the operative wound at the time of shunt insertion, leading the authors to conclude that the vulnerable period for bacterial colonization of shunts may not be restricted to the operative procedure as is commonly believed, but may extend throughout the postoperative period of wound healing. These findings have implications not only for a better understanding of the cause of shunt infections but also for the development of strategies to prevent them.

PMID: 17233307

Endovascular placement of a ventriculoatrial shunt. Technical note.

Gonzalez LF, Kim L, Rekate HL, McDougall CG, Albuquerque FC. Endovascular placement of a ventriculoatrial shunt. Technical note. Technical note. Journal of Neurosurgery. 2007 Apr;106(4 Suppl):319-21.

Atrial shunt revision surgeries are sometimes difficult due to venous occlusion and neck scarring. A direct approach guided by venography facilitates exposure and guarantees accurate placement of the distal catheter. Five patients with complicated histories of shunt malfunction were treated using an endoscope-assisted technique. The distal end of an atrial catheter was advanced into the atrium after having been connected to a venous catheter of a slightly smaller diameter than the one previously advanced from the femoral vein through the atrium. Once the position of the atrial catheter was confirmed fluoroscopically, the venous catheter was detached and removed. No complications developed in any patient. This endoscope-assisted technique offers three advantages: it demonstrates the patency of the jugular vein through venography, facilitates identification of the internal jugular vein in the neck, and provides a quick way to confirm that the distal end of the atrial catheter has been placed correctly. This technique should be considered for use in patients with a history of failed atrial shunts.

PMID: 17465370

Ascites and abdominal pseudocysts following ventriculoperitoneal shunt surgery: variations of the same theme.

Kariyattil R, Steinbok P, Singhal A, Cochrane DD. Ascites and abdominal pseudocysts following ventriculoperitoneal shunt surgery: variations of the same theme. Journal of Neurosurgery. 2007 May;106(5 Suppl):350-3.

OBJECT: Ascites and abdominal pseudocysts are two complications that can occur following placement of a ventriculoperitoneal (VP) shunt. Although various factors have been implicated, the exact pathogenesis of the two conditions remains elusive. To the authors' knowledge, there are no studies in which these two obviously related conditions have been compared.

METHODS: The authors retrospectively reviewed the cases of children with abdominal complications caused by a VP shunt. There were 15 patients who developed a pseudocyst and five patients who developed ascites. The cases were analyzed to identify common and distinguishing factors that may help in identifying the mechanism involved. Abdominal symptoms were the mode of presentation for patients with ascites, whereas shunt malfunction was the mode of presentation in 60% of those with pseudocysts. Culture-proven infection, abdominal surgery, and the number of revisions seemed to be more common in cases with pseudocysts than in ascites. The fluid in ascites was found to be a transudate irrespective of the origin of hydrocephalus. Alternative drainage sites were required in the treatment of patients with ascites, and reimplantation in the peritoneum was possible in 66.7% of those with pseudocysts. In the long-term, however, peritoneal reimplantation was possible in three of the five patients with ascites.

CONCLUSIONS: Abdominal pseudocysts and ascites, after VP shunt treatment, are distinct conditions with different modes of presentation and findings during examination of fluid, and therefore they require different management strategies.

PMID: 17566200

Predicting slitlike ventricles in children on the basis of baseline characteristics at the time of shunt insertion

Kan P, Walker ML, Drake JM, Kestle JR. Predicting slitlike ventricles in children on the basis of baseline characteristics at the time of shunt insertion. Journal of Neurosurgery. 2007 May;106(5 Suppl):347-9.

OBJECT: Slit ventricle syndrome (SVS) is a delayed complication of shunt insertion and occurs only in children with slitlike ventricles after shunt placement. Although SVS appears to be related to early shunt placement, its predisposing factors are largely unknown.

METHODS: Baseline data in 737 children who had received shunts were obtained from the databases of two previous clinical trials. Ventricular size before shunt placement and at the last routine follow up was measured using the frontooccipital horn ratio (FOHR). Ventricles with an FOHR less than or equal to 0.2 at follow up were classified as slitlike ventricles. A univariate analysis was performed on data obtained in children with more than 1 year of clinical and radiographic follow up to identify risk factors for developing slitlike ventricles. These results were entered into a multivariate analysis to identify independent predictors of slitlike ventricles. Two hundred forty-four children had more than 1 year of clinical and radiographic follow-up data. The 23 patients (9.4%) who developed slitlike ventricles had shunts inserted at a younger age (42 compared with 134 days, p = 0.09) and were more likely to have developed hydrocephalus secondary to infection (37.5%), head injury (25.0%), or aqueductal stenosis (22.2%). Slitlike ventricles were seen in 10.8% of patients with differential-pressure valves, 10.5% of patients with Delta valves, and 3.6% of patients with Orbis-Sigma valves (p = 0.007). Regression analysis supported the role of the valve type in developing slitlike ventricles.

CONCLUSIONS: Age at shunt insertion and valve type appear to be the modifiable risk factors for developing slitlike ventricles. If the authors of subsequent studies can further validate these conclusions, slow-draining valves and delayed shunt insertion might be used to decrease the incidence of slitlike ventricles and SVS.

PMID: 17566199