Tag: shunt revisión

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Revision and complication rates in adult shunt surgery

Acta Neurochirurgica (2021) 163:447–454

CSF diversion with shunt placement is frequently associated with need for later revisions as well as surgical complications. We sought to review revision and complication rates following ventriculoperitoneal, ventriculoatrial and cystoperitoneal shunt placement in adult patients, and to identify potential risk factors for revision surgery and postoperative complications.

Method Included patients were adults (≥ 18 years) who underwent primary shunt insertion at St. Olavs Hospital in Trondheim, Norway, from 2008 through 2017. The electronic medical records and diagnostic imaging from all hospitals in our catchment area were retrospectively reviewed. Follow-up ranged from 1 to 11 years. Complications were graded according to the Landriel Ibañez classification system.

Results Of the 227 patients included, 47 patients (20.7%) required revision surgery during the follow-up. In total, 90 revision surgeries were performed during follow-up. The most common cause for the first revision was infection (5.7%) and for all revisions proximal occlusion (30.0%). A total of 103 patients (45.4%) experienced ≥ 1 complication(s). Mild to moderate complications (grade I and II) were detected in 35.0% of all procedures. Severe or fatal complications (grade III and IV) were observed in 8.2% of all procedures. Urinary tract infections and pneumonia were common postoperatively (13.9% and 7.3%, respectively), and the most common IIb complication was shunt misplacement (proximally or distally). Two out of fourteen deaths within 30 days were directly associated with surgery. We did not find that aetiology/indication, age or gender influenced the occurrence of revision surgery or a grade III or IV complication.

Conclusions Shunt surgery continues to be a challenge both in terms of revision rates and procedure-related complications. However, the prediction of patients at risk remains difficult. A multidimensional focus is probably needed to reduce risks.

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Ultra-low-pressure hydrocephalic state in NPH: benefits of therapeutic siphoning with adjustable antigravity valves

Acta Neurochirurgica (2020) 162:2967–2974

Idiopathic normal-pressure hydrocephalus (NPH) is a condition of the elderly treated by ventriculoperitoneal shunt (VP) insertion. A subset of NPH patients respond only temporarily to shunt insertion despite low valve opening pressure. This study aims to describe our experience of patients who benefit from further CSF drainage by adding adjustable antigravity valves and draining CSF at ultra-low pressure.

Methods Single-centre retrospective case series of patients undergoing shunt valve revision from an adjustable differential pressure valve with fixed antigravity unit to a system incorporating an adjustable gravitational valve (Miethke proSA). Patients were screened from a database of NPH patients undergoing CSF diversion over 10 consecutive years (April 2008– April 2018). Clinical records were retrospectively reviewed for interventions and clinical outcomes.

Results Nineteen (10F:9M) patients underwent elective VP shunt revision to a system incorporating an adjustable gravitational valve. Mean age 77.1 ± 7.1 years (mean ± SD). Eleven patients (58%) showed significant improvement in walking speed following shunt revision. Fourteen patients/carers (74%) reported subjective improvements in symptoms following shunt revision.

Conclusions Patients presenting symptoms relapse following VP shunting may represent a group of patients with ultra-low pressure hydrocephalus, for whom further CSF drainage may lead to an improvement in symptoms. These cases may benefit from shunt revision with an adjustable gravitational valve, adjustment of which can lead to controlled siphoning of CSF and drain CSF despite ultra-low CSF pressure.

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Ventriculoperitoneal Shunt Surgery Outcome in Adult Transition Patients With Pediatric-Onset Hydrocephalus

Neurosurgery 70:380–389, 2012 DOI: 10.1227/NEU.0b013e318231d551

Ventriculoperitoneal shunting remains the most widely used neurosurgical procedure for the management of hydrocephalus, albeit with many complications.

OBJECTIVE: To review and assess the long-term clinical outcome of ventriculoperitoneal shunt surgery in adult transition patients with pediatric-onset hydrocephalus.

METHODS: Patients 17 years or older who underwent ventriculoperitoneal shunt placement for hydrocephalus during their pediatric years (younger than 17 years) were included. Medical charts, operative reports, imaging studies, and clinical follow- up evaluations were reviewed and analyzed retrospectively.

RESULTS: A total of 105 adult patients with pediatric-onset hydrocephalus were included. The median age of the patients was 25.9 years. The median age at the time of the initial ventriculoperitoneal shunt placement was 1.0 year. The median follow-up time for all patients was 17.7 years. The incidence of shunt failure at 6 months was 15.2%, and the overall incidence of shunt failure was 82.9%. Single shunt revision occurred in 26.7% of the patients, and 56.2% had multiple shunt revisions. The cause of hydrocephalus was significantly associated with shunt survival for patients who had shunt failure before the age of 17 years. Being pediatric at first shunt revision, infection, proximal shunt complication, and other causes were independently associated with multiple shunt failures.

CONCLUSION: The findings of this retrospective study show that the long-term ventriculoperitoneal shunt survival remains low in adult transition patients with pediatric-onset hydrocephalus.

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Management of Adult Hydrocephalus With Ventriculoperitoneal Shunts: Long-term Single- Institution Experience

Neurosurgery 69:774–781, 2011 DOI: 10.1227/NEU.0b013e31821ffa9e

Ventriculoperitoneal shunting is the most widely used neurosurgical procedure for the management of hydrocephalus.

OBJECTIVE: To evaluate our long-term single-institution experience in the management of adult hydrocephalus patients with ventriculoperitoneal shunts.

METHODS: Adult patients who underwent ventriculoperitoneal shunt placement for hydrocephalus from October 1990 to October 2009 were included. Medical charts, operative reports, imaging studies, and clinical follow-up evaluations were reviewed and analyzed retrospectively for clinical outcome in adult hydrocephalus patients.

RESULTS: A total of 683 adult patients were included in the study. The most common etiologies of hydrocephalus include idiopathic (29%), tumors and cysts (20%), postcraniotomy (13%), and subarachnoid hemorrhage (13%). The overall shunt failure rate was 32%, and the majority (74%) of shunt revisions occurred within the first 6 months. The median time to first shunt revision was 9.31 months. Etiology of hydrocephalus showed a significant impact on the incidence of shunt revision/failure and on the median time to shunt revision. Similarly, the type of hydrocephalus had a significant effect on the incidence of shunt failure and the median time to shunt revision.

CONCLUSION: A large proportion of patients (32%) experience shunt failure after shunt placement for hydrocephalus. Although the overall incidence of shunt revision was comparable to previously reported studies, the fact that a large proportion of adult populations with shunt placement experience shunt failure is a concern.

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Shunt­dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

J Neurosurg 111:1029–1035, 2009. DOI: 10.3171/2008.9.JNS08881

Chronic shunt­dependent hydrocephalus is a recognized complication of aneurysmal subarachnoid hem­ orrhage. While its incidence and risk factors have been well described, the long­term performance of shunts in this setting has not been not widely reported.

Methods. Using administrative databases, the authors derived a retrospective cohort of patients undergoing treat­ ment of a ruptured aneurysm in Ontario, Canada, between 1995 and 2005. The authors determined the incidence of shunt­dependent hydrocephalus and analyzed putative risk factors. Mortality rates and indicators of morbidity were recorded. Patients were followed up for the occurrence of shunt failure over time.

Results. Of 3120 patients in the cohort, 585 (18.75%) developed shunt-dependent hydrocephalus. On multivari­ ate analysis, age, acute hydrocephalus, ventilation on admission, aneurysms in the posterior circulation and giant aneurysms were all significant predictors of shunt-dependent hydrocephalus. The mortality rate was not increased in patients with chronic hydrocephalus (hazard ratio 1.04, p = 0.63); however, indicators of morbidity were increased in these patients. Of the 585 patients with shunt-dependent hydrocephalus, only 173 (29.6%) underwent a subsequent revision procedure. Ninety-eight percent of these revisions were completed within 6 months. Subsequent revisions occurred more frequently. On multivariate analysis, significant predictors of shunt revision included aneurysm loca­ tion in the posterior circulation and endovascular treatment of the initial ruptured aneurysm.

Conclusions. Shunt-dependent hydrocephalus affects a significant proportion of subarachnoid hemorrhage sur­ vivors, contributing to additional morbidity among these patients. Shunt failures occur less frequently in patients who underwent treatment for a ruptured aneurysm than with other forms of hydrocephalus. Most failures occur within 6 months, suggesting that shunt dependency may be transient in the majority of patients.

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