Tag: hydrocephalus

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Diagnosing Cerebrospinal Fluid Shunt Failure: Systematic Review and Meta-Analysis of Noninvasive and Minimally Invasive Tests in Children and Adults

Neurosurgery 98:1206–1220, 2026

This systematic review and meta-analysis evaluates diagnostic performance of noninvasive and minimally invasive tests (X-ray shunt series, CT, MRI, nuclear scintigraphy, thermal flow) for cerebrospinal fluid shunt failure in pediatric and adult patients, synthesizing 33 studies and 8,077 patients. Pooled accuracy was 82%, sensitivity 67%, and specificity 88%, with X-ray series showing lower sensitivity but higher specificity compared with CT.

The analysis highlights substantial study bias—especially in patient selection and reference standards—and concludes no existing test is adequate as a standalone diagnostic for shunt failure, underscoring the need to optimize diagnostic pathways, reduce harm, and develop improved point-of-care functional tests.

Objective Assess diagnostic performance of noninvasive/minimally invasive tests (X-ray shunt series, CT, MRI, nuclear scintigraphy, thermal flow evaluation) for suspected CSF shunt failure in pediatric and adult patients.

Methods Systematic review/meta-analysis (PROSPERO CRD42024596142) including patients with permanent CSF shunts who underwent the above index tests; performance (accuracy, sensitivity, specificity) modeled via meta-regression incorporating test type, age group, follow-up timeframe, and shunt type.

Evidence base PubMed search (Oct 22, 2024) screened 465 articles; 33 studies included, totaling 8077 patients.

Pooled performance Overall pooled accuracy 82%, sensitivity 67%, specificity 88% across included tests.

Key comparative finding (sensitivity) X-ray shunt series had significantly lower sensitivity than CT (OR 0.106, 95% CI 0.056–0.201; overall effect of test type on sensitivity P = .013).

Key comparative finding (specificity) No overall effect of test type on specificity (P = .192), but X-ray shunt series showed higher specificity than CT in subgroup analysis (OR 4.04, 95% CI 1.938–8.424).

Covariates No significant effects of age group, follow-up timeframe, or shunt type on accuracy, sensitivity, or specificity.

Conclusion/limitations No test performed well enough to serve as a standalone diagnostic for shunt failure; evidence limited by high risk of bias, especially in the reference standard domain for most studies.

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Suprasellar Versus Third Ventricular Cysts: Anatomic and Surgical Considerations

Operative Neurosurgery 30:468–471, 2026

This surgical case instruction contrasts suprasellar arachnoid cysts (SACs) and third ventricular cysts (3VCs), emphasizing their distinct imaging features, clinical presentations, and risks of obstructive hydrocephalus. It summarizes patient examples, MRI findings, and outcomes after endoscopic cyst fenestration, demonstrating restoration of cerebrospinal fluid flow and symptom resolution.

The article details stepwise endoscopic techniques—cyst plane development, wall reduction, excision, and membrane management—highlighting anatomical cues that guide whether endoscopic third ventriculostomy is necessary. Practical tips on preserving hypothalamic structures, restoring aqueduct patency, and minimizing reaccumulation are provided for neurosurgical practice.

Prevalence Intracranial arachnoid cysts occur in ~2.6% of children and ~1.4% of adults; suprasellar arachnoid cysts (SACs) comprise ~9%–21% of pediatric arachnoid cysts and can be confused with rarer third ventricular cysts (3VCs).

Presentation SACs and 3VCs often enlarge and cause obstructive hydrocephalus with symptoms of increased intracranial pressure, prompting urgent treatment to restore CSF circulation.

Imaging differences (SAC) SACs elevate the third ventricular floor, displace mammillary bodies superiorly/posteriorly, and elongate/stretch the midbrain and aqueduct, with aqueduct occlusion from distortion and the posterior cyst wall.

Imaging differences (3VC) 3VCs displace the third ventricular floor and mammillary bodies inferiorly with midbrain compaction; the aqueduct is obstructed by midbrain distortion and the inferoposterior cyst wall.

Treatment rationale A shunt without cyst fenestration can lead to asymmetric hydrocephalus and/or continued cyst enlargement due to cyst-related occlusion of the foramina of Monro; neuroendoscopy enables cyst fenestration with low morbidity risk at experienced centers.

Endoscopic steps A stepwise intraventricular endoscopic approach includes: developing the cyst/ventricle plane; reducing cyst wall size (coagulation); excising roof/lateral/medial walls (with caution laterally in SACs due to hypothalamic fusion); removing/reducing floating membranes (especially posteriorly) to open access to the aqueduct.

Inferior wall strategy In SACs, inferior membrane fenestration may be unnecessary because the prepontine cistern is already exposed/communicates with the third ventricle; in 3VCs, the inferior aspect is the third ventricular floor, and endoscopic third ventriculostomy (ETV) is an option.

ETV decision point If posterior membrane resection fully restores aqueduct patency, ETV may not be necessary; reducing expansile membranes is pursued to lower risk of reaccumulation from scarring.

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Lumbar Puncture or External Ventricular Drainage as Initial Treatment for Acute Hydrocephalus in Aneurysmal Subarachnoid Hemorrhage

Neurosurgery 97:1308–1315, 2025

This two-center cohort study compares lumbar puncture (LP) versus external ventricular drainage (EVD) as initial treatments for acute hydrocephalus after aneurysmal subarachnoid hemorrhage, analyzing rates of permanent ventriculoperitoneal shunts (VPS), procedure-related complications, and 3-month functional outcomes. Patients eligible for LP had similar admission severity, and outcomes were adjusted for baseline predictors to compare strategies across centers.

Results show markedly fewer permanent VPS implantations (10% vs 68%) and lower short-term complication rates with LP, while unfavorable functional outcomes at 3 months did not differ significantly. The authors conclude LP is a viable initial option for selected patients, recommending future studies on cognitive and quality-of-life effects.

Initial Treatment: Lumbar puncture (LP) as initial treatment for acute hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) resulted in significantly fewer patients requiring permanent ventriculoperitoneal shunt (VPS) implantation compared to external ventricular drainage (EVD) (10% vs 68%).

Complication Rates: LP was associated with lower short-term complication rates than EVD (21% vs 38%), including lower rates of intracerebral hemorrhage and infection, especially when LP alone was sufficient.

Functional Outcomes: No statistically significant difference was observed in unfavorable functional outcomes (Glasgow Outcome Scale 1-3 at 3 months) between LP and EVD groups, though the trend favored LP (40% vs 49%).

Patient Selection: LP is suitable as first-line treatment only for selected patients (e.g., GCS ≥7, no space-occupying hematoma, no intraventricular obstruction), while EVD remains necessary for those with contraindications to LP or requiring intracranial pressure monitoring.

Volume of CSF Drainage: Lower cerebrospinal fluid (CSF) volumes drained with LP (typically 25-30 mL per procedure) compared to EVD (hundreds of mL over days) may contribute to reduced VPS dependency.

Study Limitations: Differences in overall management strategies, patient selection, and treatment protocols between centers limit the ability to attribute outcomes solely to the initial hydrocephalus treatment modality; results should not be interpreted as definitive evidence that LP is superior to EVD.

Implications for Practice: LP can be considered as an initial treatment for acute hydrocephalus after SAH in eligible patients, but there is currently no evidence that it improves long-term functional outcomes; further research is needed to assess effects on cognition and quality of life.

Research Needs: More robust, prospective studies are required to clarify optimal patient selection, CSF drainage strategies, and comparative benefits of LP versus EVD in post-SAH hydrocephalus management.

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A Multicenter Study of Noninvasive Wireless Assessment of Cerebrospinal Fluid Shunt Function in Hydrocephalus Patients

Neurosurgery 97:1397–1405, 2025

This multicenter prospective study evaluates a wearable, wireless thermal anisotropy sensor for noninvasive detection of cerebrospinal fluid (CSF) shunt flow in symptomatic hydrocephalus patients. Using a random forest algorithm on data from 112 validated subjects, the device showed high sensitivity (88.9%) and a very high negative predictive value (96.8%), though specificity was modest (49.2%) and a 37.5% no-result rate occurred.

Methods, usability, and comparative analyses are detailed: device design, algorithm development, blinded validation, and 7-day surgical follow-up with intraoperative confirmation as ground truth. Ease-of-use was rated highly, adverse events were minor skin reactions, and combined use with CT/MRI improved specificity and overall accuracy, supporting adjunctive clinical application.

Device Purpose: A novel, noninvasive, wireless wearable device was developed to assess cerebrospinal fluid (CSF) shunt flow in hydrocephalus patients presenting with possible shunt failure, using thermal anisotropy measurements to detect flow through the shunt tubing.

Study Design: The prospective, blinded, multicenter study included both pediatric and adult patients with existing ventriculoperitoneal shunts and symptoms suggestive of shunt failure; subjects underwent device evaluation alongside standard-of-care assessments.

Algorithm Performance: The device’s random forest algorithm demonstrated high sensitivity (88.9%) and negative predictive value (NPV, 96.8%) but moderate specificity (49.2%) for detecting complete shunt failure, indicating strong ability to rule out failure when flow is confirmed.

Clinical Utility: The high NPV suggests the device could help identify patients whose shunts are functioning, potentially reducing unnecessary surgical interventions or additional invasive tests.

Comparison with Standard Tests: Standard imaging tests (CT/MRI) showed moderate-to-high sensitivity and specificity but require radiation or sedation, whereas the device is noninvasive, wireless, and does not require such resources.

Combined Diagnostic Approach: When device results were combined with CT or MRI findings, specificity increased to 93.3% and NPV to 96.6%, supporting a potential workflow where the device is used to complement imaging for risk stratification.

Safety and Usability: The device was rated as easy to use by clinicians, with a low rate of mild, self-resolving skin redness and no serious adverse events reported.

Limitations: The device is not suitable as a stand-alone diagnostic tool due to moderate specificity and a substantial rate of incomplete measurements; further studies are ongoing to optimize performance and generalizability.

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Comprehensive Morphometric Analysis to Identify Key Neuroimaging Biomarkers for the Diagnosis of Adult Hydrocephalus Using Artificial Intelligence

Neurosurgery 96:1386–1396, 2025

This study used AI and SHAP analysis to identify five key, easily measurable 1-D neuroimaging biomarkers—FTHR, MEI, MCMI, SMLH, and CPCA—for accurately diagnosing adult non-normal pressure hydrocephalus, offering a practical, standardized, and interpretable approach to improve early detection and clinical decision-making.

• Hydrocephalus diagnosis is often inconsistent due to reliance on clinical and qualitative radiological assessments.

• This study used artificial intelligence (AI) and SHAP analysis to identify key, easily measurable neuroimaging biomarkers for adult non-normal pressure hydrocephalus (non-NPH).

• A comprehensive set of 21 morphometric features was analyzed from MRI images of 42 adult non-NPH patients and 40 healthy controls.

• Gradient Boosting was the best-performing AI classifier, achieving 0.94 accuracy and 0.97 AUC.

• Ventricular volume is the most important biomarker, but measurement is complex for clinicians.

• Five key 1-D biomarkers identified are: frontal-temporal horn ratio (FTHR), modified Evans index (MEI), modified cella media index (MCMI), sagittal maximum lateral ventricle height (SMLH), and coronal posterior callosal angle (CPCA).

• These five markers are easily measurable and provide high diagnostic accuracy, supporting practical clinical use.

• The approach addresses multicollinearity and improves diagnostic standardization, but further validation with larger datasets is needed.

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Cognitive improvement after endoscopic third ventriculostomy surgery in long-standing overt ventriculomegaly in adults

J Neurosurg 142:875–883, 2025

Endoscopic third ventriculostomy (ETV) significantly improves long-term memory and visuospatial skills in patients with long-standing overt ventriculomegaly in adults (LOVA), especially those with higher premorbid IQ. The study highlights the role of cognitive reserve in facilitating cognitive recovery post-surgery.

• Endoscopic third ventriculostomy (ETV) surgery leads to cognitive improvement in patients with long-standing overt ventriculomegaly in adults (LOVA), particularly in long-term memory and visuospatial skills.

• Cognitive reserve (CR) plays a crucial role in predicting cognitive recovery post-surgery, with higher premorbid IQ linked to better outcomes.

• LOVA is a chronic form of hydrocephalus that becomes symptomatic in adulthood, often characterized by cognitive deficits and gait disturbances.

• ETV is favored over ventriculoperitoneal shunt (VPS) due to lower complication rates, making it the preferred treatment option.

• Preoperative cognitive profiles of LOVA patients show deficits primarily in long-term memory and visuospatial skills, while other cognitive domains remain unaffected.

• Postoperative improvements are significant and sustained over time, with the majority of patients reporting enhanced cognitive function and quality of life.

• Symptom duration does not hinder the efficacy of ETV, and longer symptom history may lead to better outcomes in visuospatial skills.

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Antibiotic-Impregnated Ventriculoperitoneal Shunts Decrease Bacterial Shunt Infection: A Systematic Review and Meta-Analysis

Neurosurgery 95:1263–1273, 2024

Antibiotic-impregnated shunts seem to be beneficial in preventing bacterial infections and decreasing mortality by effectively inhibiting microbial growth in the shunt system and reducing the risk of shunt-associated infections. This study aimed to evaluate the efficacy of antibiotic-impregnated shunt catheters (AISC) in reducing the incidence of bacterial shunt infection in patients with hydrocephalus.

METHODS: The protocol was registered on PROSPERO. A meta-analysis was conducted by searching 3 databases (PubMed, Scopus, CENTRAL) for relevant randomized controlled trials and observational studies. We included all studies published until November 2022 in any language. The primary outcome was the rate of bacterial infections, whereas the rate of shunt failure was our secondary endpoint. Odds ratios (OR) with 95% CI were calculated using a random-effects model.

RESULTS: A total of 27 articles with 27 266 shunt operations were included in this study. The results indicated that using AISC is significantly associated with reduction in infections (OR = 0.42; 95% CI: 0.33-0.54). Regarding shunt failure, there was a tendency in favor of AISC use (OR = 0.73; 95% CI: 0.51-1.06).

CONCLUSION: Our study provided evidence that AISC is significantly associated with the reduction in the rate of bacterial ventriculoperitoneal-shunt infection. In addition, there was a tendency toward AISC to decrease shunt failure compared with the standard shunt.

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Effect of cranial entry site on the rate of proximal catheter misplacement in ventriculoperitoneal shunt insertion

J Neurosurg 141:1418–1426, 2024

The insertion of a ventriculoperitoneal shunt (VPS) is a common neurosurgical procedure, but the optimal entry site of the ventricular catheter is still under debate. In this study, the authors compare the parietal (Keen’s) and frontal (Kocher’s) entry sites in terms of the rate of revision surgery due to ventricular catheter misplacement, VPS dysfunction, and VPS infection.

METHODS The authors retrospectively analyzed the data on consecutive adults (age ≥ 18 years) who had undergone primary VPS insertion between 2010 and 2020 at two neurosurgical centers. One center regularly inserts the ventricular catheter frontally (frontal group); the other center, parietally (parietal group). The primary outcome of interest was the rate of ventricular catheter misplacement necessitating revision surgery. Secondary outcomes were functional outcome as measured by the modified Rankin Scale (mRS), rate of revision surgery for VPS dysfunction and infection, as well as early (≤ 30 days) and late (> 30 days) mortality rates. Propensity score matching was performed based on baseline variables, such as normal pressure hydrocephalus, postinfectious hydrocephalus, and idiopathic intracranial hypertension, which were identified as predictors of ventricular catheter misplacement using logistic regression analysis.

RESULTS Among 539 consecutive patients, 301 (55.8%) were in the frontal group and 238 (44.2%) in the parietal group. Postoperative rates of revision surgery due to misplacement were comparable in the two catheter entry site groups (frontal 14 [4.7%] vs parietal 11 [4.6%], p = 0.987). Rates of revision surgery for VPS dysfunction (14 [4.7%] vs 10 [4.2%], respectively, p = 0.802) and infection (22 [7.3%] vs 10 [4.2%], p = 0.13) exhibited no significant differences. Favorable functional outcomes (mRS score ≤ 2; 164 [76.3%] vs 174 [79.5%], respectively, p = 0.058) and early mortality rates (5 [1.7%] vs 6 [2.5%], p = 0.483) were similar between the groups. After propensity score matching, the primary and secondary outcome measures remained comparable between the groups.

CONCLUSIONS The entry site of the ventricular catheter in VPS surgery does not seem to affect proximal revision rates. Further, revision rates due to VPS dysfunction, VPS infection, and morbidity were comparable as well.

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Microcirculatory Impairment and Cerebral Injury in Hydrocephalus and the Effects of Cerebrospinal Fluid Diversion

Neurosurgery 95:469–479, 2024

Hydrocephalus is characterized by progressive enlargement of cerebral ventricles, resulting in impaired microvasculature and cerebral hypoperfusion. This study aimed to demonstrate the microvascular changes in hydrocephalic rats and the effects of cerebrospinal fluid (CSF) release on cerebral blood flow (CBF).

METHODS: On postnatal day 21 (P21), male Wistar rats were intracisternally injected with either a kaolin suspension or saline. On P47, Evan’s ratio (ER) was measured using MRI. On P49, the arteriolar diameter and vascular density of the pia were quantified using a capillary video microscope. The CBF was measured using laser Doppler flowmetry. The expressions of NeuN and glial fibrillary acidic protein determined by immunochemical staining were correlated with the ER. The CBF and rotarod test performance were recorded before and after CSF release. The expressions of 4-hydroxynonenal (4-HNE) and c-caspase-3 were studied on P56.

RESULTS: Ventriculomegaly was induced to varying degrees, resulting in the stretching and abnormal narrowing of pial arterioles, which regressed with increasing ER. Quantitative analysis revealed significant decreases in the arteriolar diameter and vascular density in the hydrocephalic group compared with those in the control group. In addition, the CBF in the hydrocephalic group decreased to 30%–50% of that in the control group. In hydrocephalus, the neurons appear distorted, and the expression of 4-HNE and reactive astrogliosis increase in the cortex. After CSF was released, improvements in the CBF and rotarod test performance were inversely associated with the ER. In addition, the levels of 4-HNE and c-caspase-3 were further elevated.

CONCLUSION: Rapid ventricular dilatation is associated with severe microvascular distortion, vascular regression, cortical hypoperfusion, and cellular changes that impair the recovery of CBF and motor function after CSF release. Moreover, CSF release may induce reperfusion injury. This pathophysiology should be taken into account when treating hydrocephalus.

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Ventriculoatrial Shunt Versus Ventriculoperitoneal Shunt: A Systematic Review and Meta-Analysis

Neurosurgery 94:903–915, 2024

Ventriculoperitoneal shunt (VPS) is usually the primary choice for cerebrospinal fluid shunting for most neurosurgeons, while ventriculoatrial shunt (VAS) is a second-line procedure because of historical complications. Remarkably, there is no robust evidence claiming the superiority of VPS over VAS. Thus, we aimed to compare both procedures through a meta-analysis.

METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, the authors systematically searched the literature for articles comparing VAS with VPS. The included articles had to detail one of the following outcomes: revisions, infections, shunt-related mortality, or complications. In addition, the cohort for each shunt model had to encompass more than 4 patients.

RESULTS: Of 1872 articles, 16 met our criteria, involving 4304 patients, with 1619 undergoing VAS and 2685 receiving VPS placement. Analysis of revision surgeries showed no significant difference between VAS and VPS (risk ratio [RR] = 1.10, 95% CI: 0.9-1.34; I 2 = 84%, random effects). Regarding infections, the analysis also found no significant difference between the groups (RR = 0.67, 95% CI: 0.36-1.25; I 2 = 74%, random effects). There was no statistically significant disparity between both methods concerning shunt-related deaths (RR = 2.11, 95% CI: 0.68-6.60; I 2 = 56%, random effects). Included studies after 2000 showed no VAS led to cardiopulmonary complications, and only 1 shunt-related death could be identified.

CONCLUSION: Both methods show no significant differences in procedure revisions, infections, and shunt-related mortality. The literature is outdated, research in adults is lacking, and future randomized studies are crucial to understand the profile of VAS when comparing it with VPS. The final decision on which distal site for cerebrospinal shunting to use should be based on the patient’s characteristics and the surgeon’s expertise.

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Radionuclide shuntography for cerebrospinal fluid shunt flow evaluation in adults

J Neurosurg 140:621–626, 2024

Radionuclide shuntography (RS) performed using 99m Tc-DTPA injected into the reservoir of CSF shunts enables evaluation of CSF flow for suspected shunt malfunctions. The goal of this study was to report the authors’ institutional experience with RS and evaluate its utility and associated complications.

METHODS The authors retrospectively reviewed all RS studies performed between November 2003 and June 2022. Patients with shunted hydrocephalus who were ≥ 18 years of age were included. Patients undergoing RS for evaluation of Ommaya reservoirs were excluded. Demographics, hydrocephalus etiology, presenting symptoms, study results, subsequent management, complications, and intraoperative diagnoses were recorded. Chi-square tests were reported for categorical variables and standard 2 × 2 contingency methods were used for sensitivity/specificity analysis.

RESULTS The authors identified 211 RS procedures performed in 142 patients. The mean age at procedure was 55.6 ± 20.9 years (mean ± SD). Normal pressure hydrocephalus was the most common hydrocephalus etiology (37.0%), followed by congenital malformations (26.1%) and idiopathic intracranial hypertension (15.6%). Successful radionuclide injection was achieved in 207 studies (98.1%). Shunt patency was confirmed in 63.8% of successful injections, whereas malfunction was demonstrated in 27.1% and abnormally slow flow was seen in 9.2%. RS studies demonstrating shunt malfunction were more likely to result in subsequent revisions than were studies showing patency (86.6% vs 2.9%; p < 0.0001). The overall sensitivity and specificity of RS for detecting shunt malfunction was 92.3% and 96.2%, respectively. The median follow-up time was 29 months, with 151 cases having ≥ 6 months of follow-up. There were no complications or infections attributable to RS in this cohort.

CONCLUSIONS RS is a useful and safe tool in the workup of shunt malfunction.

 

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Dorsum Sellae as Key Landmark in ETV With Disminished Prepontine Cistern

Operative Neurosurgery 26:188–195, 2024

One of the key aspects in the surgical technique of endoscopic third ventriculostomy (ETV) is the perforation of the floor of the third ventricle because of the high risk of injuring vital structures located in that region. According to the standard technique, this perforation should be performed in the midline halfway between mammillary bodies and the infundibular recess to avoid damage to the structures. This can be performed without excessive complications when the diameter of the prepontine cistern is wide. However, in situations where the diameter is reduced (defined in the literature as having a prepontine interval [PPI] ≤1 mm), the probability of complications increases exponentially. In this article, we propose using dorsum sellae as a key point to safely perform ETV in patients with a decreased PPI, guiding the trajectory and its marking using neuronavigation.

METHODS: A review was conducted on the latest 100 ETV procedures performed by our team in the past 5 years. The measurement of the PPI was conducted using archived preoperative MRI imaging studies, specifically between the dorsum sellae and the basilar artery. In cases where the PPI was ≤1 mm and, therefore, the use of the dorsum sellae was applied as a reference point, the technical results and procedural functions were documented.

RESULTS: In the cohort, 7 patients with a PPI ≤1 mm were identified. In all 7 cases, fenestration of the tuber cinereum was successfully performed without causing vascular damage or associated complications. ETV was successful in 6 patients, with only one experiencing ETV failure necessitating the placement of a ventriculoperitoneal shunt.

CONCLUSION: The utilization of the dorsum sellae as a reference point to perform ETV in reduced PPI constitutes a safe alternative to the classical technique.

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Navigated bedside implantation of external ventricular drains with mobile health guidance

Acta Neurochirurgica (2024) 166:76

External ventricular drain (EVD) implantation is one of the fundamental procedures of emergency neurosurgery usually performed freehand at bedside or in the operating room using anatomical landmarks. However, this technique is frequently associated with malpositioning leading to complications or dysfunction. Here, we describe a novel navigated bedside EVD insertion technique, which is evaluated in a clinical case series with the aim of safety, accuracy, and efficiency in neurosurgical emergency settings.

Methods From 2021 to 2022, a mobile health–assisted navigation instrument (Thomale Guide, Christoph Miethke, Potsdam, Germany) was used alongside a battery-powered single-use drill (Phasor Health, Houston, USA) for bedside EVD placement in representative neurosurgical pathologies in emergency situations requiring ventricular cerebrospinal fluid (CSF) relief and intracranial pressure (ICP) monitoring.

Results In all 12 patients (8 female and 4 male), navigated bedside EVDs were placed around the foramen of Monro at the first ventriculostomy attempt. The most frequent indication was aneurysmal subarachnoid hemorrhage. Mean operating time was 25.8 ± 15.0 min. None of the EVDs had to be revised due to malpositioning or dysfunction. Two EVDs were converted into a ventriculoperitoneal shunt. Drainage volume was 41.3 ± 37.1 ml per day in mean. Mean length of stay of an EVD was 6.25 ± 2.8 days. Complications included one postoperative subdural hematoma and cerebrospinal fluid infection, respectively.

Conclusion Combining a mobile health–assisted navigation instrument with a battery-powered drill and an appropriate ventricular catheter may enable and enhance safety, accuracy, and efficiency in bedside EVD implantation in various pathologies of emergency neurosurgery without adding relevant efforts.

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Neuronavigated foraminoplasty, shunt removal, and endoscopic third ventriculostomy in a 54‑year‑old patient with third shunt malfunction episode

Acta Neurochirurgica (2023) 165:3289–3296

The application of endoscopic third ventriculostomy (ETV) for the treatment of obstructive hydrocephalus in shunt malfunction represents a paradigm shift, as it allows hydrocephalus to be transformed from a chronic condition treated with an artificial device to a curable disease.

Methods We present a 54-year-old male with a diagnosis of idiopathic Sylvian aqueduct stenosis treated with shunt. The patient presented to our institution with symptoms of shunt malfunction and an increase in ventricular size on imaging, which was his third episode throughout his life. Through a right precoronal approach, with prior informed consent from the patient, we performed foraminoplasty, endoscopic third ventriculostomy, and finally removal of the shunt system.

Conclusion ETV shows promise as a viable treatment option for shunt malfunction in noncommunicating obstructive hydrocephalic patients. Its potential to avoid VPS-related complications, preserve physiological CSF circulation, and provide an alternative drainage pathway warrants further investigation.

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Ventriculosinus shunt: a pilot study to investigate new technology to treat hydrocephalus and mimic physiological principles of cerebrospinal fluid drainage

J Neurosurg 139:1412–1419, 2023

Devices draining CSF to the intracranial venous sinus for the treatment of hydrocephalus have been tested in the past, and while clinically effective, have not shown efficacy in the long term. The majority of these devices become obstructed within 3 months due to endothelial overgrowth. In this study, the authors investigated a newly developed ventriculosinus (VS) shunt outlet device with the objective of showing it would remain patent for at least 6 months.

METHODS Twelve patients in need of shunting for hydrocephalus underwent an operation using the investigational device and were followed for 6 months to record patency of the shunt.

RESULTS In 10 patients, the shunt was patent at 6 months, with the outlet device remaining unobstructed. In the remaining 2 patients, one died just before reaching the 6-month endpoint, and in the other the outlet was misplaced during surgery and therefore ceased to function after 3 months. No occlusion of the internal jugular vein or thrombus formation was noted in any of the 12 cases.

CONCLUSIONS These findings indicate that the outlet device can remain patent and has the capability to mimic physiological drainage by diverting CSF to the intracranial sinus. Additional confirmation of its potential as part of a new VS shunt system and ultimately as a viable alternative for ventriculoperitoneal and ventriculoatrial shunting to reduce complication rates requires further clinical trials.

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Retrospective comparison of long‑term functionality and revision rate of two different shunt valves in pediatric and adult patients

Acta Neurochirurgica (2023) 165:2541–2549

The most frequent therapy of hydrocephalus is implantation of ventriculoperitoneal shunts for diverting cerebrospinal into the peritoneal cavity. We compared two adjustable valves, proGAV and proGAV 2.0, for complications resulting in revision surgery.

Methods Four hundred patients undergoing primary shunt implantation between 2014 and 2020 were analyzed for overall revision rate, 1-year revision rate, and revision-free survival observing patient age, sex, etiology of hydrocephalus, implantation site, prior diversion of cerebrospinal fluid, and cause of revision.

Results All data were available of all 400 patients (female/male 208/192). Overall, 99 patients underwent revision surgery after primary implantation. proGAV valve was implanted in 283 patients, and proGAV 2.0 valves were implanted in 117 patients. There was no significant difference between the two shunt valves concerning revision rate (p = 0.8069), 1-year revision rate (p = 0.9077), revision-free survival (p = 0.6921), and overall survival (p = 0.3232). Regarding 1-year revision rate, we observed no significant difference between the two shunt valves in pediatric patients (40.7% vs 27.6%; p = 0.2247). Revision operation had to be performed more frequently in pediatric patients (46.6% vs 24.8%; p = 0.0093) with a significant higher number of total revisions with proGAV than proGAV 2.0 (33 of 59 implanted shunts [55.9%] vs. 8 of 29 implanted shunts [27.6%]; p = 0.0110) most likely due to longer follow-up in the proGAV-group. For this reason, we clearly put emphasis on analyzing results regarding 1-year revision rate.

Conclusion According to the target variables we analyzed, aside from lifetime revision rate in pediatric patients, there is no significant difference between the two shunt valves.

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The Management of Hydrocephalus in Midline Posterior Fossa Cystic Collections

Neurosurgery 93:576–585, 2023

Hydrocephalus frequently occurs with midline posterior fossa cystic collections. The classification of this heterogeneous group of developmental anomalies, including Dandy–Walker malformation, persisting Blake’s pouch, retrocerebellar arachnoid cysts, and mega cisterna magna, is subject of debate. The absence of diagnostic criteria is confusing regarding the ideal management of PFCC-related hydrocephalus.

OBJECTIVE: To decipher the surgical strategy for the treatment of children with PFCC-related hydrocephalus through a retrospective analysis of the surgical outcome driven by their clinical and radiological presentation.

METHODS: This study enrolled patients operated of symptomatic PFCC-related hydrocephalus. Clinical and MRI features were examined, as well as the surgical outcome. Unbiased subgroup classification of the patients was performed with multiple component analysis as a function of imaging characteristics and hierarchical clustering on principal component. Outcome was assessed with binomial logistic regression and Kaplan–Meier analysis.

RESULTS: Fifty-four patients were included between 2007 and 2021. Multiple component analysis suggested that cerebellar and vermian hypoplasia, vermian rotation, basal–tentorial angle, and fastigial angle were strongly correlated. Hierarchical clustering and the distribution of the patients in the bidimensional plot showed the clear segregation of 3 major clusters, which correlated with the radiological diagnosis (P < .01). Binomial logistic regression and survival analysis showed that endoscopic third ventriculostomy was an effective treatment for patients with persisting Blake’s pouch, while failing to control hydrocephalus in most of patients with Dandy–Walker malformation.

CONCLUSION: Preoperative MRI in patients with PFCC-related hydrocephalus is essential to better define the diagnosis. The choice of treatment strategy notably relies on correct radiological diagnosis.

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Robot‑assisted endoscopic third ventriculostomy under intraoperative CT imaging guidance

Acta Neurochirurgica (2023) 165:2525–2531

The robot-assisted neurosurgical procedures have recently benefited of the evolution of intraoperative imaging, including mobile CT unit available in the operating room. This facilitated use paved the way to perform more neurosurgical procedures under robotic assistance. Endoscopic third ventriculocisternostomy requires both a safe transcortical trajectory and a smooth manipulation.

Method We describe our technique of robot-assisted endoscopic third ventriculocisternostomy combining robotic assistance and intraoperative CT imaging.

Conclusion Robot-assisted endoscopic third ventriculocisternostomy using modern intraoperative neuroimaging can be easily implemented and prevented erroneous trajectory and abrupt endoscopic movements, reducing surgically induced brain damages.

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Initial Clinical Experience and Biomechanical Analysis of a Novel Gravity Unit–Assisted Valve (M.blue) in Pediatric Patients With Hydrocephalus

Neurosurgery 93:555–562, 2023

Overdrainage is a widely reported complication representing common indication for shunt revision. Despite recent advances in valve design, repeated shunt revisions represent burden on healthcare systems.

OBJECTIVE: To investigate the efficiency of a novel gravity unit–assisted programmable valve “M.blue” in pediatric hydrocephalus using clinical and biomechanical analyses.

METHODS: This retrospective single-center study included pediatric patients who received M.blue valve between April 2019 and 2021. Several clinical and biomechanical parameters were documented including complications and revision rates. Flow rate, functional assessment in vertical and horizontal positions, and extent of depositions inside valve were analyzed in explanted valves.

RESULTS: Thirty-seven M.blue valves in 34 pediatric patients with hydrocephalus (mean age 2.82 ± 3.91 years) were included. Twelve valves (32.4%) were explanted during a follow-up period of 27.3 ± 7.9 months. One-year survival rate of 89% and overall survival rate of 67.6% with a valve survival average of 23.8 ± 9.7 months were observed. Patients with explanted valves (n = 12) were significantly younger, with 0.91 ± 0.54 years of age in average (P= .004), and showed significantly more adjustments difficulties (P= .009). 58.3% of explanted valves showed deposits in more than 75% of the valve surface despite normal cerebrospinal fluid findings and were associated with dysfunctional flow rate in vertical, horizontal, or both positions.

CONCLUSION: The novel M.blue valve with integrated gravity unit is efficient in pediatric hydrocephalus with comparable survival rate. Deposits inside valves could affect its flow rate in different body positions and might lead to dysfunction or difficulties in valve adjustments.

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Cerebral Microbleeds—Long-Term Outcome After Cerebrospinal Fluid Shunting in Idiopathic Normal Pressure Hydrocephalus

Neurosurgery 93:300–308, 2023

Cerebral microbleeds (CMBs) are common in idiopathic normal pressure hydrocephalus (INPH) and have been suggested as radiological markers of a brain prone to bleeding. The presence of CMBs might be relevant when selecting patients for shunt surgery.

OBJECTIVE: To evaluate whether CMBs increases long-term risk of hemorrhagic complications and mortality or affects outcomes after cerebrospinal fluid shunt surgery in a cohort of patients with INPH.

METHODS: One hundred and forty nine shunted patients with INPH (mean age, 73 years) were investigated with MRI (T2* or susceptibility-weighted imaging sequences) preoperatively. CMBs were scored with the Microbleed Anatomic Rating Scale. Patients were observed for a mean of 6.5 years (range 2 weeks to 13 years) after surgery. Hemorrhagic events and death were noted. Improvement in gait was evaluated 3 to 6 months after surgery.

RESULTS: At baseline, 74 patients (50%) had CMBs. During follow-up, 7 patients (5%) suffered a hemorrhagic stroke and 43 (29%) suffered a subdural hematoma/hygroma with a median time from surgery of 30.2 months (IQR 50). Overall, having CMBs was not associated with suffering a subdural hematoma/hygroma or hemorrhagic stroke during follow-up with 1 exception that an extensive degree of CMBs (≥50 CMB) was more common in patients suffering a hemorrhagic stroke (P = .03). CMBs were associated with increased mortality (P = .02, Kaplan-Meier, log-rank test). The presence of CMBs did not affect gait outcome (P = .28).

CONCLUSION: CMBs were associated with hemorrhagic stroke and mortality. CMBs do not seem to reduce the possibility of gait improvement after shunt surgery or contribute to the risk of hemorrhagic complications regarding subdural hematoma or hygroma.

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