Parental diagnosis of shunt malfunction in children.

IntroductionEvaluation of shunt for malfunction and blockage is a common neurosurgical clinical scenario in day-to-day paediatric neurosurgery practice. Parental concern for shunt malfunction is normally considered a reliable indication for undertaking further assessment of a child with a shunt. Accuracy of parental diagnosis of shunt malfunction likely is dependent on combination of parental knowledge and patient symptomatology and familiarity of symptoms in relation to previous shunt malfunction symptoms. There are currently no UK studies on accuracy of parental diagnosis of shunt malfunction. We undertook this study to investigate sensitivity and specificity of parental diagnosis in our tertiary paediatric neurosurgical unit to identify any factors that can be used for further education and raising awareness in parents with children with shunts.MethodsWe undertook a review of all referrals with suspected shunt malfunction to our tertiary paediatric neurosurgical unit over a period of 10 months. All referrals and presentations were evaluated for parental concern for likelihood of shunt malfunction and marked as yes or no. Further information gathered included demographics, age, sex, symptoms at presentation, previous history of shunt revision, cases of shunt malfunction and part of the shunt revised. Sensitivity, specificity, positive and negative predictive values and accuracy were then calculated and factors associated with positive diagnosis of shunt malfunction analysed.ResultsOverall, 100 referrals with suspected shunt malfunction were made over 10 months period. Mean age for children at the time of referral was 6.3 years with an M/F ratio of 42M:58F. Twenty-one shunt malfunction cases were identified leading to overall revision rate of 21%. Parental evaluation of shunt function had sensitivity of 90.4%, specificity of 10.1%, positive predictive value of 21.1% and negative predictive value of 80%. Drowsiness and higher number of symptoms at presentation were associated with true positive diagnosis of shunt malfunction. No link was identified with true diagnosis of shunt malfunction with other symptoms of shunt malfunction or previous history of shunt revision and age of the patient.ConclusionParental diagnosis of shunt malfunction has high sensitivity and negative predictive value and low specificity and positive predictive value. Increased number of symptoms as well as drowsiness were associated with correct parental diagnosis of shunt malfunction. Educational programs and parental training can be valuable in increasing awareness about shunt malfunction signs.

Ventricular catheter tissue obstruction and shunt malfunction in 9 hydrocephalus etiologies.

OBJECTIVE: Hydrocephalus is a neurological disorder with an incidence of 80-125 per 100,000 births in the United States. The most common treatment, ventricular shunting, has a failure rate of up to 85% within 10 years of placement. The authors aimed to analyze the association between ventricular catheter (VC) tissue obstructions and shunt malfunction for each hydrocephalus etiology. METHODS: Patient information was collected from 5 hospitals and entered into a REDCap (Research Electronic Data Capture) database by hydrocephalus etiology. The hardware samples were fixed, and each VC tip drainage hole was classified by tissue obstruction after macroscopic analysis. Shunt malfunction data, including shunt revision rate, time to failure, and age at surgery, were correlated with the degree of tissue obstruction in VCs for each etiology. RESULTS: Posthemorrhagic hydrocephalus was the most common etiology (48.9% of total cases). Proximal catheter obstruction was the most frequent cause of hardware removal (90.4%). Myelomeningocele (44% ± 29%), other congenital etiologies (48% ± 40%), hydrocephalus with brain tumors (45% ± 35%), and posthemorrhagic hydrocephalus (41% ± 35%) showed tissue aggregates in more than 40% of the VC holes. A total of 76.8% of samples removed because of symptoms of obstruction showed cellular or tissue aggregates. No conclusive etiological associations were detected when correlating the percentage of holes with tissue for each VC and age at surgery, shunt revision rates, or time between shunt implantation and removal. CONCLUSIONS: The proximal VC obstruction was accompanied by tissue aggregates in 76.8% of cases. However, the presence of tissue in the VC did not seem to be associated with hydrocephalus etiology.

The Utilization of Computed Tomography in the Pediatric Emergency Department for Patients With Ventriculoperitoneal Shunts.

Introduction Despite all the advantages of computed tomography (CT) scanning, there is a significant concern due to the rising use of CT scans in children with ventriculoperitoneal (VP) shunts. High doses of radiation are absorbed by patients, raising their chance of acquiring cancer. Evaluating a potential VP shunt malfunction is a frequent encounter in the pediatric emergency room, often necessitating the utilization of a CT scan. This study aims to recognize and quantify the utilization of CT scans in an emergency setting for pediatric patients with a clinical suspicion of VP shunt malfunction. Methods This retrospective chart review was conducted on patients who visited the emergency department with suspected VP shunt malfunction in a pediatric tertiary care hospital (King Abdullah Specialist Children Hospital), Riyadh, Saudi Arabia. The study included the files of children between the years 2018 and 2019. Results A total of 119 children were included; the main indication for VP shunt insertion was congenital hydrocephalus at 46.8% (n=52). The median number of CT scans done per patient was seven (IQR=3-9). CT findings were abnormal among 55.6% (n=60). The univariate analysis examining the impact of different factors on CT findings showed an association between an abnormal CT finding and female gender (P=0.017), younger age (P=0.03), and the presence of a cerebral cyst (P=0.001); however, subsequent multivariate analysis was not significant for any of these factors. Twenty-two point three percent (n=25) of the patients required neurosurgical intervention, and the associated factors with neurosurgical intervention included changes in activity level (P=0.04), weakness (P=0.004), and altered mental status (P=0.001). Conclusion Children with VP shunts are susceptible to significant radiation exposure through the utilization of CT scans whenever they present to the ER with suspected shunt malfunction during their lifespan, which puts them at risk of radiation-related complications, such as cancers. CT imaging remains a helpful tool aiding physicians in making accurate decisions. However, in this study, almost half of the children had unremarkable CT findings. Thus, it is imperative to rationalize its use by establishing tailored guidelines that delineate the appropriate circumstances warranting its application.

Clinical and socioeconomic predictors of shunt malfunction in the pediatric emergency department.

OBJECTIVE: The aim of this study was to delineate the clinical and socioeconomic variables associated with shunt revision in pediatric patients presenting to the emergency department (ED) with concerns of ventricular shunt malfunction. METHODS: A retrospective analysis of pediatric ED consultations for shunt malfunction over a 1-year period was conducted, examining clinical symptoms, radiographic findings, and socioeconomic variables. Sensitivities, specificities, and positive and negative predictive values were calculated for each presenting symptom collected. Logistic regression models were used to estimate the odds ratios for shunt revision based on these variables, and multivariate analyses were used to adjust for potential confounders. RESULTS: Of the 271 ED visits from 137 patients, 19.2% resulted in shunt revision. Increased ventricle size on imaging (OR 11.38, p < 0.001), shunt site swelling (OR 9.04, p = 0.01), bradycardia (OR 7.08, p < 0.001), and lethargy (OR 5.77, p < 0.001) were significantly associated with shunt revision. Seizure-like activity was inversely related to revision needs (OR 0.24, p < 0.001). Patients with private or self-pay insurance were more likely to undergo revision compared with those with public insurance (p = 0.028). Multivariate analysis further confirmed the significant associations of increased ventricle size, lethargy, and bradycardia with shunt revision, while also revealing that seizure-like activity inversely affected the likelihood of revision. Patients with severe cognitive and language disabilities were more likely to be admitted to the hospital from the ED but were not more likely to undergo revision. CONCLUSIONS: Clinical signs such as increased ventricle size, shunt site swelling, bradycardia, and lethargy may be strong predictors of the need for shunt revision in pediatric patients presenting to the ED with concerns of shunt malfunction. Socioeconomic factors play a less clear role in predicting shunt revision and admission from the ED; however, the nature of their influence is unclear. These findings can help inform clinical decision-making and optimize resource utilization in the ED.

Seizures as presentation of shunt malfunction: tertiary paediatric neurosurgery experience.

AIM: Patients with a background of cerebrospinal fluid (CSF)-diverting shunts are frequently investigated for shunt malfunction when presenting with seizures. However, there is very limited evidence in the literature regarding the association of seizures and shunt malfunction. We sought to determine the incidence of shunt malfunction in our cohort of shunted paediatric patients presenting with seizures, and the utility of seizures as a marker of shunt malfunction. METHODS: We retrospectively identified all shunted patients presenting with seizures, as well as all patients undergoing shunt revision following a presentation with seizures from our hospital database over a 14-year period from 2009 to 2023. Data gathered included demographics, de novo seizures or change in pattern of seizures, the aetiology of hydrocephalus and the segment of shunt requiring revision. Exclusion criteria included infected cases requiring shunt externalisation. A literature review of all papers discussing seizures as a presentation of shunt malfunction was also carried out. RESULTS: Overall, over a 14-year period of study, 338 shunted patients presented with seizures and were referred as suspected shunt malfunction with 10 having confirmed shunt malfunction requiring revision (2.9%). This group represented 6.2% of 161 cases of shunt revision carried out during the 14-year period of study. Post-haemorrhagic hydrocephalus secondary to prematurity was the commonest aetiology of shunted hydrocephalus presenting with seizures. Out of 10 patients presenting with seizures with shunt malfunction, 4 presented with de novo seizures, while 6 presented with a change in seizure pattern or frequency in already known epileptic patients. Shunt revision surgeries included 5 distal catheter, 2 proximal catheter, 1 proximal catheter-valve, 1 valve only and 1 case of whole shunt change. CONCLUSION: Our data supports that seizures are rare manifestation of shunt malfunction and can present either de novo or with a change in seizure frequency in already-known epileptic patients.

Ventriculoperitoneal shunt infection rate and other associated complications of VP shunt insertion in Abuja, Nigeria.

Background: Complications associated with ventriculoperitoneal shunt insertion constitute a significant cause of morbidity and mortality among hydrocephalus patients. Despite this, VP shunt placement has remained the mainstay of treatment for hydrocephalus. The aim of this study is to evaluate the complications of VP shunt surgery in our environment and to identify the risk factors associated with it. Methodology: Patients who had VP shunt surgery over a period of two years (Jan 2015-December 2016) were evaluated retrospectively by reviewing their hospital records. The patients' demography, aetiology and clinical presentation of the hydrocephalus, and complications were analysed using SPSS version 26.0. Results were presented in tables and figures. Results: A total of 69 patients who had VP shunt over the study period had complete medical records available for review. Their age ranged between 2days and 68years with a male to female ratio of 1.8:1. Overall complication rate was 30.4%. Shunt malfunction (11.5%) and shunt infection (7.2%) were the commonest complications recorded. Late presentation was the most important risk factor for shunt complications. Conclusion: The rate of shunt complications seen in this study compares fairly with studies in other parts of the world.

Scintigraphic Detection of Abdominal Pseudocyst: A Complication of Ventriculoperitoneal Shunt.

We report a case of a large abdominal pseudocyst detected on scintigraphy in a patient with a history of ventriculoperitoneal shunt placement who presented with headache and suspected shunt malfunction.

Management of cerebrospinal fluid pseudocysts in the laparoscopic age.

OBJECTIVE: Abdominal CSF pseudocysts are an uncommon but challenging complication of ventriculoperitoneal shunts. Pseudocysts consist of a loculated intraperitoneal compartment that inadequately absorbs CSF and may be infected or sterile at diagnosis. The treatment goal is to clear infection if present, reduce inflammation, and reestablish long-term function in an absorptive (intraperitoneal) space. This aim of this paper was to study the efficacy of primary laparoscopic repositioning of the distal shunt catheter for treatment of sterile abdominal CSF pseudocysts. METHODS: All patients treated for abdominal CSF pseudocysts at Dallas Children's Health from 1991 to 2021 were retrospectively reviewed. Patient history and pseudocyst characteristics were analyzed, with a primary outcome of pseudocyst recurrence at 1 year. RESULTS: Of 92 primary pseudocysts, 5 initial treatment strategies (groups) were used depending on culture status, clinical history, and surgeon preference: 1) shunt explant/external ventricular drain (EVD) placement (23/92), 2) distal tubing externalization (13/92), 3) laparoscopic repositioning (35/92), 4) open repositioning (4/92), and 5) other methods such as pseudocyst drainage or direct revision to another terminus (17/92). Seventy pseudocysts underwent shunt reimplantation in the peritoneal space. The 1-year peritoneal shunt survival for groups 1 and 2 combined was 90%, and 62% for group 3. In group 3, 1-year survival was better for those with normal systemic inflammatory markers (100%) than for those with high markers (47%) (p = 0.042). In a univariate Cox proportional hazards model, the risk of pseudocyst recurrence was increased if the most recent abdominal procedure was a nonshunt abdominal surgery (p = 0.012), and it approached statistical significance with male sex (p = 0.054) and elevated inflammatory markers (p = 0.056. Multivariate Cox analysis suggested increased recurrence risk with male sex (p = 0.05) and elevated inflammatory markers (p = 0.06), although the statistical significance threshold was not reached. The length of hospital stay was shorter for laparoscopic repositioning (6 days) than for explantation/EVD placement (21 days) (p < 0.0001). Ultimately, 62% of patients had a peritoneal terminus at the last follow-up, 33% (n = 30) had an extraperitoneal terminus (19 pleura, 8 right heart, and 3 gallbladder), and 5 patients were shunt free. CONCLUSIONS: Some sterile pseudocysts with normal systemic inflammatory markers can be effectively treated with laparoscopic repositioning, resulting in a significantly shorter hospitalization and modestly higher recurrence rate than shunt explantation.

Ventriculoperitoneal shunt survey in pediatric patients in an emergency setting: a comparison between ultra-low-dose CT using a tin filter and plain radiography.

OBJECTIVE: The aim of this study was to investigate the diagnostic performance, effective radiation dose, and examination time of ventriculoperitoneal shunt evaluation using full-body ultra-low-dose CT (ULD CT) with a tin filter compared with digital plain radiography in a pediatric population. METHODS: A retrospective cross-sectional study was conducted in an emergency setting. Data from 143 children were collected. Sixty were examined with ULD CT with a tin filter and 83 with digital plain radiography methods. Effective doses and times were compared between the two methods. Two observers in pediatric radiology evaluated the patient images. Clinical findings and results from shunt revision, if it was performed, were used to evaluate the diagnostic performance between modalities. An examination-room simulation was performed of the two methods to estimate representative examination times. RESULTS: The mean effective radiation dose for ULD CT with the tin filter was estimated to be 0.29 ± 0.16 mSv compared with 0.16 ± 0.19 mSv for digital plain radiography, with both examinations associated with a very low lifetime attributable risk (< 0.01%). The shunt tip could be more reliably located with ULD CT. ULD CT also allowed assessment of additional findings to explain patient symptoms, such as a cyst at the tip of the shunt catheter and the presence of an obstructing rubber nipple in the duodenum that could not have been observed on a plain radiograph. The examination time with ULD CT of the shunt was estimated to be 20 minutes. The examination time of the shunt with digital plain radiography, including the examination itself time and transfer of the patient between rooms, was estimated to be 60 minutes. CONCLUSIONS: ULD CT using a tin filter allows good visualization of the position or disruption of the shunt catheter that is comparable or superior to plain radiography, at a higher dose, while providing additional findings and reduced patient discomfort.

Endoscopic Third Ventriculostomy in a 12-Year-Old With Recurrent Failure of Ventriculoperitoneal Shunts.

With a success rate of about 80%, ventriculoperitoneal (VP) shunts are widely used for the treatment of hydrocephalus. Whether congenital or acquired, hydrocephalus is not a single disease entity. It can be caused by abnormal cerebrospinal fluid (CSF) reabsorption, obstruction along the ventricular pathways, or, very rarely, increased production of CSF itself. This case presents a patient with a history of congenital hydrocephalus with multiple failed VP shunts. Through various clinical examinations and diagnostic measures, an endoscopic third ventriculostomy was eventually performed. This case highlights the rare complications, yet a large possibility, that can lead to failure of VP shunts in more than one way and when it is appropriate for shunt reversal versus removal.

Odd presentation of shunt malfunction: a case series and review of literature.

OBJECTIVE: Children with previous ventriculoperitoneal shunt (VPS) insertion due to hydrocephalus may refer to the hospital with various clinical complaints. Shunt malfunction is frequently diagnosed in these children necessitating shunt revision. Although increased head circumference, setting sun eye in younger children, and headache, nausea/vomiting, loss of consciousness, visual disturbance, and other signs of intracranial hypertension are common clinical manifestations of shunt malfunction, some patients may present with odd or unusual symptoms. Here, we present a series of patients with shunted hydrocephalus who presented with odd and unexpected clinical manifestations of shunt malfunction. METHODS: Eight children with shunt malfunction were enrolled in this series. The age, sex, age of shunting, etiology of hydrocephalus and management, post-shunt insertion symptoms/sign, revision surgery, outcome, and follow-up were evaluated. RESULTS: Patients were aged from 1 to 13 years (mean, 6.38 years). There were 5 males and 3 females. The odd presentation associated with shunt malfunction included facial palsy in three children, ptosis in 3 children, and torticollis and dystonia each in one child. All patients underwent shunt revision except for one patient in whom a new shunt was inserted. Follow-up showed improvement of the symptoms in all patients. CONCLUSION: In this series, we reported eight patients with unusual signs and symptoms following shunt malfunction that were successfully diagnosed and managed.

Symptoms of Cerebrospinal Shunt Malfunction in Young Children: A National Caregiver Survey.

Objective: This study aimed to describe shunt malfunction symptoms in children ≤5 years old. Results: In a national survey of 228 caregivers, vomiting (23.1%), irritability (20.8%), and sleepiness (17.2%) were the most frequent symptoms of malfunction. These symptoms also occurred in over 1/3 of "false alarms" experienced by 75% of respondents. Compared with malfunctions, irritability (OR = 1.39, 95% CI [1.05, 1.85], p = 0.022) and fever (OR = 2.22, 95% CI [1.44, 3.44], p < 0.001) were more likely false alarms. Caregivers counseled about "most" symptoms were more confident detecting malfunctions than those informed of "some" (p = 0.036). The majority of caregivers (85%) first contacted a neurosurgeon with concerns about malfunction, followed by neurologists (22%) and family/friends (19%). Most (85%) struggled to differentiate malfunction from regular development. Conclusions: Vomiting, irritability, and sleepiness were the most common symptoms of shunt malfunction and false alarms for children ≤5 years. Most caregivers reported challenges differentiating malfunctions from their child's development.

Shunt Migration in Children: A Patient Level Systematic Review of Risk Factors and Outcome.

Ventriculoperitoneal shunt insertion is one of the most common pediatric neurosurgical procedures performed. Shunt migration is one of the infrequent complications of shunt insertion and often requires a change of the shunt system. The objective of the study is to systematically review the sites of shunt migration and factors associated with mortality in children. Comprehensive search and review of the literature were done according to the PRISMA guidelines. Citations were selected using the following inclusion criteria: 1. Shunt migration in ventriculoperitoneal shunts was the primary inclusion criteria, 2. Age of the study participants <18 years, and 3. Patient-level data available in the study. Exclusion criteria were 1. Age >18 years, 2. Patient-level data not available, 3. Full text of the article not available, and 4. Article not in the English language. Sites of migration and risk factors for mortality were assessed. In total, 111 studies out of 161 studies were included in the final analysis. The scrotum was the most common site of shunt migration (30.67%), followed by anal migration, migration into the bowel, chest wall/thoracic migration, and intracranial/subgaleal migration. Univariate analysis showed the presence of infection and site of migration to be significantly associated with mortality. Multivariate analysis showed the presence of infection and age at presentation to be significant predictors of mortality. This study highlights that presence of infection is a significant predictor of mortality in cases of shunt migration. Infection should be managed expeditiously for optimum management of shunt migration.

Neointimal hyperplasia in systemic-to-pulmonary shunts of children with complex cyanotic congenital heart disease.

OBJECTIVES: Neointimal hyperplasia might affect systemic-to-pulmonary shunt failure in infants with complex cyanotic congenital heart disease. The aim of this study was to elucidate histopathologic changes in polytetrafluoroethylene shunts and to determine whether increased neointimal formation is associated with early interventions comprising balloon dilatation, stent implantation and shunt revision. Furthermore, we intended to identify clinical factors associated with increased neointimal proliferation. METHODS: Removed shunts were processed for histopathological analysis. Slides were stained with hematoxylin/eosin and Richardson. Immunohistochemistry was performed with anti-alpha-smooth muscle actin and anti-CD68. Non-parametric analysis and univariable regressions were performed to identify clinical factors associated with neointimal hyperplasia and shunt stenosis. RESULTS: Fifty-seven shunts (39 modified Blalock-Taussig anastomosis, 8 right ventricle-to-pulmonary artery anastomosis, 10 central shunts) were analysed. Area of neointimal proliferation within the shunt was in median 0.75 mm2 (interquartile range, 0.3-1.57 mm2) and relative shunt stenosis in median 16.7% (interquartile range, 6.7-30.8%). Neointimal hyperplasia and shunt stenosis correlated with each other and were significantly greater in the group that required early interventions and shunt revision. Univariable linear regression identified smaller shunt size and lower acetylsalicylic acid dosage as factors to be associated with greater neointimal proliferation and shunt stenosis. CONCLUSIONS: In infants with complex cyanotic congenital heart disease, neointimal hyperplasia in systemic-to-pulmonary shunts is associated with early interventions comprising balloon dilatation, stent implantation and shunt revision. Smaller shunt size and lower aspirin dosage are associated with increased neointimal proliferation.

Risk of ventriculoperitoneal shunt malfunction in operatively treated early onset spinal deformity.

PURPOSE: Ventriculoperitoneal (VP) shunt placement is a common neurosurgical procedure performed in patients with early onset scoliosis (EOS). To provide insight into the risks of spine lengthening operations, we investigate the rate of VP shunt complications in patients with EOS undergoing spinal deformity correction interventions. METHODS: A retrospective review was performed of all patients with EOS at a single institution undergoing spinal deformity correction procedures from 2007 to 2018. Patients having undergone VP shunt implantation prior to deformity correction were included. A minimum of 2-year follow-up was required for inclusion. Clinical records and imaging studies were reviewed. RESULTS: Nineteen patients with VP shunts underwent Vertical Expandable Prosthetic Titanium Rib (VEPTR) implantation for treatment of early onset spinal deformity. The mean age at shunt placement and spine instrumentation surgery was 13.7 months (1 day to 13 years) and 6.1 years (0.5-15.1) respectively. The diagnoses associated with shunt implantation were: 12 spina bifida, 3 structural defects or obstructions, 2 intraventricular hemorrhage, 1 cerebral palsy, and 1 campomelic dwarfism. During the first 2 years following rib-based insertion, there was a mean of 2.5 expansion/revision procedures (0-5) with no shunt-related complications. The mean length of follow-up in this series was 7.0 years (2.6-13.2). A total of three (16%) patients required shunt revision following their rib-based device insertion, two patients with proximal shunt malfunctions and one with a mid-catheter breakage, at 2.4, 2.6, and 5.6 years, respectively, after rod implantation (Fig. 2). Each of these shunt revisions occurred more than 50 days following an expansion procedure (1.9, 2.9, and 5.7 months, respectively). CONCLUSION: Growing instrumentation procedures in EOS are associated with low risk for post-operative shunt complications in patients with ventriculoperitoneal shunts. There were no shunt revision procedures performed in the first 2 years following rib-based device insertion. Sixteen percent of patients went on to require a shunt revision at some point during their follow-up, which is comparable to the baseline rate of shunt revision in non-EOS patients. LEVEL OF EVIDENCE: IV, Case series.

Ventriculoperitoneal Shunt Malfunction in a Pediatric Patient Due to Compression by Skull Growth: A Case Report.

There are various causes of ventriculoperitoneal shunt (VPS) failures. Patients who receive shunt placement during childhood need follow-up for decades as they grow, especially in the early periods of life. Herein, we report a rare case of mechanical shunt obstruction in a pediatric patient in whom a cramped burr hole and skull growth compressed the tube and obstructed cerebrospinal fluid flow. A 6-year-old girl presented to our hospital with nausea and headache. She was born preterm and developed intraventricular hemorrhage followed by VPS placement for hydrocephalus; thereafter, she had no need for shunt revision until this admission. After careful evaluation of the patency of the shunt system, the presence of tube stenosis was suspected at the site of the shunt tube penetrating the burr hole of the skull. During the operation to revise the shunt tube, a compressed tube was observed at the exit from the skull. After enlarging the narrowed burr hole and reconstructing the proximal catheter, her symptoms immediately improved. Previously, only one case of shunt malfunction due to tube compression from bone growth has been reported in a pediatric patient with osteopetrosis. To the best of our knowledge, such a condition has never been described in pediatric patients with no metabolic bone disease. Although it is rare, obstruction at the exit from the skull due to bone growth should be included in differential diagnoses for young patients during a long follow-up after VPS.

Weight and Abdominal Pressure-Induced Shunt Trouble in Patients With Shunted Normal Pressure Hydrocephalus: A Comprehensive Study on Pressure Environment of Shunt System.

Objectives: We identified a new type of shunt malfunction (SM) in patients with normal pressure hydrocephalus (NPH). It is induced by weight change and can be treated with valve readjustment. There were two types of SM as follows: Underdrainage induced by the weight gain and overdrainage induced by the weight loss. This study aims to elucidate this mechanism by assessing the shunt pressure environment. Methods: The total pressure environment of the shunt system was prospectively studied in patients with shunted NPH at Osaka Medical College Hospital from 1999 to 2005. We measured the pressure environment during the initial pressure setting of the valve by the intracranial pressure (ICP) guide, after setting the valve, and when SM was suspected. We evaluated ICP, intra-abdominal pressure (IAP), and hydrostatic and perfusion pressures of the shunt system in the sitting and supine positions. The target ICP for valve setting was empirically set at the range from -8 to -13 mm Hg in the sitting position, referring to the external auditory meatus. During the study period, we identified five cases of SM induced by weight change and assessed the changes in the pressure environment across pre-SM, SM, and post-SM. Results: In four cases of underdrainage, gait disturbance worsened with an average weight gain of 6.8 ± 1.2 kg. With weight gain, IAP and ICP increased by 8.8 ± 1.6 and 4.8 ± 1.0 mm Hg, respectively. Consequently, ICP increased to -6.5 ± 1.9 mm Hg. One overdrainage patient developed an asymptomatic chronic subdural hematoma (CSDH) with a weight loss of 10 kg. With the weight loss, both IAP and ICP decreased by 5 mm Hg, and concomitantly, ICP decreased to -18 mm Hg. In all patients, the valve readjustment restored their ICP to the target pressure. After the valve readjustment, the gait disturbance improved immediately, and the CSDH disappeared after 1 month. Conclusion: In patients with shunts, the weight change was linked to ICP via IAP. Due to the weight change, the underdrainage occurred when ICP was above the target pressure, and the overdrainage occurred when ICP was below it. We named this SM as the weight and abdominal pressure-induced shunt trouble. The patients with SM along with weight changes should be the first to be tried for the valve readjustment.

The Shunt Slippage: A Complication of Pumping Test.

Surgery for the placement of a ventriculoperitoneal shunt incurs numerous procedure-related complications. Distal dislodgment of the device from the cranial insertion site after pumping of the shunt chamber has rarely occurred and it has not been evaluated to date. Herein, we report an interesting case of a 20-year-old man who underwent shunt revision for ventricular catheter migration after a manual pumping test. We reviewed previously reported cases related to such rare conditions and described a simple method of valve fixation for preventing disconnection and migration of the proximal shunt system.

Transient ventriculoperitoneal shunt malfunction in a pediatric patient: An illustrative case.

BACKGROUND: Ventriculoperitoneal shunt (VPS), the mainstay of the treatment for hydrocephalus, is associated with relatively high revision rates. Transient hydrocephalus due to intermittent VPS obstruction should be recognized as a cause of VPS malfunction. While transient VPS dysfunction is well-recognized complication, there is a relative paucity of well-documented cases in the literature. CASE DESCRIPTION: We present the case of a 4-year-old boy with a history of vascular malformation and hydrocephalus secondary to intraventricular hemorrhage. The patient presented with transient, self-resolving hydrocephalus (without intervention), as documented by clinical and radiological findings. CONCLUSION: Transient hydrocephalus due to intermittent VPS dysfunction in children is a rare entity, but it should be suspected in certain patients with VPS presenting with transient or self-improving symptoms.

OS reboot.

Cerebrospinal fluid (CSF) diversion or shunting procedures are the most commonly performed surgery for the treatment of hydrocephalus and are often employed in the management of elevated intracranial pressure due to a variety of diseases. Despite their popularity however, approximately 50% of shunts fail within the first two years, and several revisions are required within the first decade after placement. Ophthalmologists may encounter patients with a CSF shunt to evaluate for concerns of vision loss or diplopia and to determine if papilledema is present. We discuss the neuro-ophthalmic manifestations and evaluation of possible CSF shunt malfunction.