Tag: shunt

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Shunting for the Treatment of Arachnoid Cysts in Children

Neurosurgery 67:1632–1636, 2010 DOI: 10.1227/NEU.0b013e3181f94476

The optimal treatment of symptomatic arachnoid cysts remains controversial.

OBJECTIVE: We present a single-institution experience on surgical treatment of arachnoid cysts.

METHODS: Between January 1983 and January 2008, 92 patients with symptomatic arachnoid cysts underwent surgery at our institute. All patients were evaluated with CT and/or MRI and were operated upon and had regular follow-up examinations.

RESULTS: There were 60 males and 32 females. The mean age was 3.6 years (range, 2 days to 14 years). Forty-eight cysts (52%) were within the sylvian fissure, 16 (17%) were in the cerebral convexity, 15 (16%) were infratentorial, 10 (11%) were in the interhemispheric fissure, and 3 (4%) were parasellar. Cystoperitoneal shunt was placed in 67 (73%) patients; ventricular drainage alone was performed in 14 (15%) patients; and combined drainage of the ventricular system and cyst, using a 3-way connector, was performed in 8 (9%) patients. Craniotomy and fenestration of the cyst was performed in 2 (2%) patients, whereas total excision of the cyst was performed in 1 patient. Shunt revision for various reasons was performed in 34 patients (39%), whereas 13 (14%) patients required more than one revision. Complete alleviation of symptoms was achieved in all patients after treatment, regardless of cyst reduction. After a mean follow-up of 8.5 years no further enlargement of the arachnoid cysts was noted.

CONCLUSION: Shunt placement is a safe and effective surgical treatment of symptomatic arachnoid cysts in children. Cyst reduction is greater in children younger than 2 years of age.

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Investigating shunt function using continuous intracranial pressure monitoring in adults: single center experience

J Neurosurg 113:1326–1330, 2010. (DOI: 10.3171/2010.8.JNS1067)

Managing symptomatic ventriculoperitoneal shunts with no clear evidence of shunt malfunction either clinically or radiologically can be a difficult task. The aim of this study was to assess intracranial pressure (ICP) monitoring as a method of investigating shunt function.

Methods. The authors performed a retrospective analysis of 38 continuous ICP monitoring procedures done in patients with ventriculoperitoneal shunts and suspected shunt malfunction.

Results. Thirty-eight procedures were performed in 31 patients between January 2005 and October 2008. Sixteen recordings were normal, 6 revealed overdrainage or low pressure, 11 indicated underdrainage or high pressure, and 5 showed variable shunt function. Based on the findings after 20 procedures (53%), patients were treated conservatively: 4 by readjusting the valve setting and 16 by referral to the headache neurologist for medical treatment. Forty-five percent of the conservatively treated patients improved. Surgical exploration was undertaken following 18 procedures (47%); 72% of the surgically treated patients improved.

Conclusions. Continuous ICP monitoring using an intraparenchymal probe is a safe and effective method of investigating adult hydrocephalus.

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The Adjustable proGAV Shunt: A Prospective Safety and Reliability Multicenter Study

Neurosurgery 66:465-474, 2010 DOI: 10.1227/01.NEU.0000365272.77634.6B

OBJECTIVE: To evaluate the reliability of the gravitation-assisted adjustable proGAV shunt system with a prospective multicenter study conducted in 10 German hospitals.

METHODS: Enrollment for this observational study began in April 2005 and concluded in February 2006. The protocol required re-examinations 3 and 6 months postoperatively and fixed the endpoint of follow-up at 12 months after implantation. Patients with different types of adult, juvenile, and pediatric hydrocephalus were included and 165 patients were enrolled; 9 died and 12 had incomplete follow-up.

RESULTS: Of the assessable 144 patients, 130 completed the protocol after 12 months, whereas 14 failed because of the need to explant the device, mainly because of infection. In 12 patients, components of the shunt, not the valve, were revised. In 65 of the 144 patients, there were 102 readjustments of the valve in 67 incidences because of underdrainage and in 35 because of overdrainage. In 1 case, readjustment was not possible. Determination of pressure level with the verification instrument was safe and corresponded to the required x-ray controls after adjustments. No unintended readjustments were noted.

CONCLUSION: The proGAV is a safe and reliable device.

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Is All “Communicating” Hydrocephalus Really Communicating? Prospective Study on the Value of 3D-Constructive Interference in Steady State Sequence at 3T

Am J Neuroradiol 30:1898 –906.DOI 10.3174/ajnr.A1726

BACKGROUND AND PURPOSE: 3D-constructive interference in steady state (3D-CISS) sequence has been used to assess the CSF pathways. The aim of this study was to investigate the additive value of 3D-CISS compared with conventional sequences in the diagnosis of obstructive membranes in hydrocephalus.

MATERIALS AND METHODS: A total of 134 patients with hydrocephalus underwent MR imaging examination with a 3T unit consisting of turbo spin-echo, 3D-CISS, and cine phase-contrast (cine PC) sequences. 3D-CISS was used to assess obstructive membranes in CSF pathways compared with other sequences. Cine PC, follow-up imaging, and surgical findings were used to confirm obstructive membranes.

RESULTS: Comparing the number of noncommunicating cases by using the conventional and 3D-CISS images, we found 26 new cases (19.4%) of 134 cases that were previously misdiagnosed as communicating hydrocephalus by conventional images. 3D-CISS sequence identified obstructive membranes invisible in other sequences, which facilitated selection of neuroendoscopy in the treatment of 31 patients (23.1%) in total who would have been otherwise treated with shunt insertion. These patients included 26 newly diagnosed noncommunicating cases after demonstration of intraventricular and/or fourth ventricular outlet membranes and 5 cases of communicating hydrocephalus with obstructing cisternal membranes. There were obstructions of the foramina of Luschka in 22 of 26 newly found noncommunicating cases.

CONCLUSIONS: Conventional sequences are insensitive to obstructive membranes in CSF pathways, especially in the fourth ventricular exit foramina and the basal cisterns. 3D-CISS sequence, revealing these obstructive membranes, can alter patient treatment and prognosis.

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Experiences with a gravity-assisted valve in hydrocephalic children

J Neurosurg Pediatrics 4:020880–200930, 2009. (DOI: 10.3171/2009.4.PEDS08204)

Over the past decade, a gravity-assisted valve (GAV) has become a standard device in many European pediatric hydrocephalus centers. Because past comparative clinical outcome studies on valve design have not included any GAV, the authors in this trial evaluated the early results of GAV applications in a pediatric population.

Methods. For a minimum of 2 years the authors monitored 169 of 182 hydrocephalic children who received a pediatric GAV at their first CSF shunt insertion (61.5%) or as a substitute for any differential pressure valve (38.5%) at 1 of 7 European pediatric hydrocephalus centers. Outcomes were categorized as valve survival (primary outcome) or shunt survival (secondary outcome). The end point was defined as valve explantation.

Results. Within a follow-up period of 2 years, the valve remained functional in 130 (76.9%) of 169 patients. One hundred eight of these patients (63.9%) had an uncomplicated clinical course without any subsequent surgery, and 22 (13%) were submitted to a valve-preserving catheter revision without any further complications during the follow- up period. Thirty-nine patients (23.1%) reached an end point of valve explantation: 13 valve failures from infection (7.7%), 8 (4.7%) from overdrainage, and 18 (10.6%) from underdrainage.

Conclusions. Compared with nongravitational shunt designs, a GAV does not substantially affect the early complication rate. Valve-preserving shunt revisions do not increase the risk of subsequent valve failure and therefore should not be defined as an end point in studies on valve design. A significant impact of any well-established valve design on the early complication rate in shunt surgery is not supported by any current data; therefore, this correlation should be dismissed. As overdrainage-related complications have been shown to occur late, the presumed advantages of a pediatric GAV remain to be shown in a long-term study.

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