Readmissions after ventricular shunting in pediatric patients with hydrocephalus: a Nationwide Readmissions Database analysis.

OBJECTIVE: Cerebrospinal fluid diversion via ventricular shunting is a common surgical treatment for hydrocephalus in the pediatric population. No longitudinal follow-up data for a multistate population-based cohort of pediatric patients undergoing ventricular shunting in the United States have been published. In the current review of a nationwide population-based data set, the authors aimed to assess rates of shunt failure and hospital readmission in pediatric patients undergoing new ventricular shunt placement. They also review patient- and hospital-level factors associated with shunt failure and readmission. METHODS: Included in this study was a population-based sample of pediatric patients with hydrocephalus who, in 2010-2014, had undergone new ventricular shunt placement and had sufficient follow-up, as recorded in the Nationwide Readmissions Database. The authors analyzed the rate of revision within 6 months, readmission rates at 30 and 90 days, and potential factors associated with shunt failure including patient- and hospital-level variables and type of hydrocephalus. RESULTS: A total of 3520 pediatric patients had undergone initial ventriculoperitoneal shunt placement for hydrocephalus at an index admission. Twenty percent of these patients underwent shunt revision within 6 months. The median time to revision was 44.5 days. Eighteen percent of the patients were readmitted within 30 days and 31% were readmitted within 90 days. Different-hospital readmissions were rare, occurring in ≤ 6% of readmissions. Increased hospital volume was not protective against readmission or shunt revision. Patients with grade 3 or 4 intraventricular hemorrhage were more likely to have shunt malfunctions. Patients who had private insurance and who were treated at a large hospital were less likely to be readmitted. CONCLUSIONS: In a nationwide, population-based database with longitudinal follow-up, shunt failure and readmission were common. Although patient and hospital factors were associated with readmission and shunt failure, system-wide phenomena such as insufficient centralization of care and fragmentation of care were not observed. Efforts to reduce readmissions in pediatric patients undergoing ventricular shunt procedures should focus on coordinating care in patients with complex neurological diseases and on reducing healthcare disparities associated with readmission.

Factors Affecting the Intensive Care Stay of Patients with Spinal Neural Tube Defects.

AIM: To evaluate the duration of hospitalization and the factors that increase this duration in cases treated in the neonatal intensive care unit with the diagnosis of a spinal neural tube defect (NTD). MATERIAL AND METHODS: The demographic characteristics, NTD type and level, ventriculoperitoneal (V-P) shunt needs, accompanying spinal deformity, antibiotherapy applied during treatment, and intensive care stay periods of 73 patients treated in our clinic between July 2017 and 2020 were retrospectively evaluated. RESULTS: The intensive care stay of NTD cases was 7?109 (mean=23) days. Fifty-one cases (69.9%) had myeloschisis, and 22 cases (30.1%) had myelomeningocele (MMC) sac. A V-P shunt was applied to 24 cases (32.9%) during hospitalization, and additional antibiotherapy was given to 32 (43.8%) cases. CONCLUSION: In myeloschisis cases compared with MMC marsupial cases, incidences of ventricular dilatation, kyphotic/scoliotic spine pathology, V-P shunt requirement, and longer hospital stay were observed. No difference in the duration of hospitalization was found in patients who underwent defect repair between the first day and 48 h after birth. However, the length of stay in hospital increased in patients operated on after 48 h. The period was longer in cases operated after seven days postnatally. Therefore, by performing NTD surgical treatment within the first 48 hours, the need for additional antibiotherapy and hospital stay can be shortened.

Percutaneous fetoscopic spina bifida repair: effect on ambulation and need for postnatal cerebrospinal fluid diversion and bladder catheterization.

OBJECTIVE: A trial comparing prenatal with postnatal open spina bifida (OSB) repair established that prenatal surgery was associated with better postnatal outcome. However, in the trial, fetal surgery was carried out through hysterotomy. Minimally invasive approaches are being developed to mitigate the risks of open maternal-fetal surgery. The objective of this study was to investigate the impact of a novel neurosurgical technique for percutaneous fetoscopic repair of fetal OSB, the skin-over-biocellulose for antenatal fetoscopic repair (SAFER) technique, on long-term postnatal outcome. METHODS: This study examined descriptive data for all patients undergoing fetoscopic OSB repair who had available 12- and 30-month follow-up data for assessment of need for cerebrospinal fluid (CSF) diversion and need for bladder catheterization and ambulation, respectively, from eight centers that perform prenatal OSB repair via percutaneous fetoscopy using a biocellulose patch between the neural placode and skin/myofascial flap, without suture of the dura mater (SAFER technique). Univariate and multivariate logistic regression analyses were used to examine the effect of different factors on need for CSF diversion at 12 months and ambulation and need for bladder catheterization at 30 months. Potential cofactors included gestational age at fetal surgery and delivery, preoperative ultrasound findings of anatomical level of the lesion, cerebral lateral ventricular diameter, lesion type and presence of bilateral talipes, as well as postnatal findings of CSF leakage at birth, motor level, presence of bilateral talipes and reversal of hindbrain herniation. RESULTS: A total of 170 consecutive patients with fetal OSB were treated prenatally using the SAFER technique. Among these, 103 babies had follow-up at 12 months of age and 59 had follow-up at 30 months of age. At 12 months of age, 53.4% (55/103) of babies did not require ventriculoperitoneal shunt or third ventriculostomy. At 30 months of age, 54.2% (32/59) of children were ambulating independently and 61.0% (36/59) did not require chronic intermittent catheterization of the bladder. Multivariate logistic regression analysis demonstrated that significant prediction of need for CSF diversion was provided by lateral ventricular size and type of lesion (myeloschisis). Significant predictors of ambulatory status were prenatal bilateral talipes and anatomical and functional motor levels of the lesion. There were no significant predictors of need for bladder catheterization. CONCLUSION: Children who underwent prenatal OSB repair via the percutaneous fetoscopic SAFER technique achieved long-term neurological outcomes similar to those reported in the literature after hysterotomy-assisted OSB repair. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Prevalence and Trends in Management of Idiopathic Normal Pressure Hydrocephalus in the United States: Insights from the National Inpatient Sample.

BACKGROUND: Over the past 2 decades, management of idiopathic normal pressure hydrocephalus (iNPH) has evolved significantly. In the current study, we sought to evaluate the national prevalence and management trends of iNPH in the United States using a national database. METHODS: The National Inpatient Sample was queried for patients with an International Classification of Diseases diagnosis code for iNPH from 2007 to 2017. Trends in prevalence and procedure type were evaluated per 100,000 discharges and as a percentage of discharges, using weighted discharges. Utilization of procedure type across U.S. regions and hospital types was also compared. RESULTS: From 2007 to 2017, 302,460 weighted discharges with any diagnosis code for iNPH, aged ≥60 years, were identified. Prevalence ranged from 0.04% to 0.20% (41/100,000 to 202/100,000) among admitted patients ≥60 years old, giving an average prevalence during the study duration of 0.18% (179/100,000). Of 66,759 weighted discharges with a primary diagnosis code of iNPH undergoing surgical management, ventriculoperitoneal shunt (72.0% of discharges, n = 48,977) was most commonly used; of these, 9.3% (n = 4567) were performed laparoscopically. This result was followed by lumbar peritoneal shunt (15.1% of discharges, n = 10,441). Up to 15.1% (n = 9990) of discharges reported only a lumbar puncture, assumed to be only diagnostic, for screening, or part of serial cerebrospinal fluid removal procedures. Significant discrepancies in procedure utilization were also identified among hospitals in the Western, Southern, Northeast and Midwest regions, as well as between urban and rural hospitals (P < 0.05). CONCLUSIONS: We have summarized the national prevalence of iNPH, trends in its management over the previous decade and trends by region and hospital type.

An Expedited Intracranial Pressure Monitoring Protocol Following Spontaneous CSF Leak Repair.

OBJECTIVE: Spontaneous cerebrospinal fluid (CSF) leaks represent a unique subset of skull base pathology and require distinctive management. Perioperative evaluation and management of intracranial hypertension are essential in preventing further erosion of the skull base and development of recurrent leak. The objective of this study is to evaluate the safety and utility of an expedited protocol for recording and managing intracranial hypertension following endoscopic repair of spontaneous CSF leaks. METHODS: Prospectively collected data was reviewed in patients undergoing endoscopic repair of spontaneous CSF leaks between January 2017 and March 2020. A standard intracranial pressure monitoring protocol was compared to an expedited protocol (EP), and data regarding the two groups was compared for leak location, short-term success of skull base repair, complications, hospital length of stay, and cost-based analysis. RESULTS: Fifty-five patients (standard protocol, n = 28 vs. EP, n = 27) were included in the study. Leak location was similar between cohorts, with the lateral recess being the most common locations in both groups (37.9% vs. 40.6%; P = .90). Postoperative complications (3.6% vs. 7.4%; P = .53) and ventriculoperitoneal shunt rate (32.1% vs. 22.2%; P = .41) were similar among cohorts. There was no difference in lumbar drain complications (0% vs. 7.4%; P = .14) or recurrent leak (7.1% vs. 0%; P = .16). Length of stay was shorter in the EP group [median(interquartile range): 3(1) vs. 2 (1); P < .01]. Total hospital charges were similar between groups (median (USD/$1,000): 83.57 ± 49.58 vs. 83.93 ± 46.11; P = .18). CONCLUSION: An expedited monitoring protocol shortened hospital stay without increased risk of complications. LEVEL OF EVIDENCE: III Laryngoscope, 131:E408-E412, 2021.

External Validation of Scoring Models to Predict Shunt Insertion after Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: The current study is an external validation of 4 scoring models proposed in the literature for predicting ventriculoperitoneal shunt insertion after aneurysmal subarachnoid hemorrhage (aSAH) using retrospective patient data from Sheffield Teaching Hospital (STH). METHODS: Data were collected on various demographics, and patients were individually scored using the 4 scoring models. Models were compared with each other using receiver-operator characteristic curves. The best model had the highest area under the curve. RESULTS: A total of 301 aSAH patients were referred to the neurosurgery department in STH between 1 January 2014 and 31 December 2017. Scoring model 4 also had the largest area under the curve of 0.853 (P < 0.001), and scoring model 3 had the lowest area under the curve of 0.654 (P = 0.036). CONCLUSIONS: Scoring model 4 was found to be the best scoring model out of the 4 scoring models externally validated to predict shunt dependency after an aSAH in STH patients. Scoring model 4 is less applicable in modern practice due to a higher proportion of coiling and use of the Hunt and Hess scale grade. A new scoring model is needed to predict shunt insertion in modern practice.

Does the skull Hounsfield unit predict shunt dependent hydrocephalus after decompressive craniectomy for traumatic acute subdural hematoma?

BACKGROUND AND PURPOSE: Posttraumatic hydrocephalus affects 11.9%-36% of patients undergoing decompressive craniectomy (DC) after traumatic brain injury and necessitates a ventriculo-peritoneal shunt placement. As bone and arachnoid trabeculae share the same collagen type, we investigated possible connections between the skull Hounsfield unit (HU) values and shunt-dependent hydrocephalus (SDHC) in patients that received cranioplasty after DC for traumatic acute subdural hematoma (SDH). METHODS: We measured HU values in the frontal bone and internal occipital protuberance from admission brain CT. Receiver operating characteristic curve analysis was performed to identify the optimal cut-off skull HU values for predicting SDHC in patients receiving cranioplasty after DC due to traumatic acute SDH. We investigated independent predictive factors for SDHC occurrence using multivariable logistic regression analysis. RESULTS: A total of 162 patients (>15 years of age) were enrolled in the study over an 11-year period from two university hospitals. Multivariable logistic analysis revealed that the group with simultaneous frontal skull HU ≤797.4 and internal occipital protuberance HU ≤586.5 (odds ratio, 8.57; 95% CI, 3.05 to 24.10; P<0.001) was the only independent predictive factor for SDHC in patients who received cranioplasty after DC for traumatic acute SDH. CONCLUSIONS: Our study reveals a potential relationship between possible low bone mineral density and development of SDHC in traumatic acute SDH patients who had undergone DC. Our findings provide deeper insight into the association between low bone mineral density and hydrocephalus after DC for traumatic acute SDH.

Fetal open spinal dysraphism repair through a mini-hysterotomy: Influence of gestational age at surgery on the perinatal outcomes and postnatal shunt rates.

OBJECTIVE: To analyze the impact of gestational age (GA) at the time of fetal open spinal dysraphism (OSD) repair through a mini-hysterotomy on the perinatal outcomes and the infants' ventriculoperitoneal shunt rates. METHODS: Retrospective study of cases of fetal OSD correction performed from 2014 and 2019. RESULTS: One hundred and ninety women underwent fetal surgery for OSD through a mini-hysterotomy, and 176 (176/190:92.6%) have since delivered. Fetal OSD correction performed earlier in the gestational period, ranging from 19.7 to 26.9 weeks, was associated with lower rates of postnatal ventriculoperitoneal shunting (P: .049). Earlier fetal surgeries were associated with shorter surgical times (P: .01), smaller hysterotomy lengths (P < .001), higher frequencies of hindbrain herniation reversal (P: .003), and longer latencies from surgery to delivery (P < .001). Median GA at delivery was 35.3 weeks. Multivariate binary logistic regression showed that both fetal lateral ventricle-to-hemisphere ratio (%; P < .001; OR: 1.14 [95% CI: 1.09-1.21]) and GA at the time of fetal surgery (P: .016; OR: 1.37 [95% CI: 1.07-1.77]) were independent predictors of postnatal ventriculoperitoneal shunting. CONCLUSION: Fetuses with OSD who were operated on earlier in the gestational interval, which ranged from 19.7 to 26.9 weeks, were less prone to receiving postnatal ventriculoperitoneal shunts.

Predictors of Ventriculoperitoneal shunting following Subarachnoid Hemorrhage treated with External Ventricular Drainage.

BACKGROUND/OBJECTIVES: Aneurysmal subarachnoid hemorrhage (aSAH) is commonly associated with hydrocephalus due to subarachnoid hemorrhage blood products obstructing cerebrospinal fluid outflow. Hydrocephalus after aSAH is routinely managed with temporary external ventricular drainage (EVD) followed by standard EVD weaning protocols, which determine the need for ventriculoperitoneal shunting (VPS). We sought to investigate aSAH patients who initially passed EVD weaning trials and had EVD removal, but later presented with recurrent, delayed, symptomatic hydrocephalus requiring a VPS. METHODS: We conducted a retrospective review of all patients at our tertiary care medical center who presented with aSAH, requiring an EVD. We analyzed variables associated with ultimate VPS dependency during hospitalization. RESULTS: We reviewed 489 patients with aSAH over a 6-year period (2008-2014). One hundred and thirty-eight (28.2%) developed hydrocephalus requiring a temporary EVD. Forty-four (31.9%) of these patients died or had withdrawal of care during admission, and were excluded from final analysis. Of the remaining 94 patients, 29 (30.9%) failed their clamp trial and required VPS. Sixty-five (69.1%) patients passed their clamp trial and were discharged without a VPS. However, 10 (15.4%) of these patients developed delayed hydrocephalus after discharge and ultimately required VPS [mean (range) days after discharge, 97.2 (35-188)]. Compared to early VPS, the delayed VPS group had a higher incidence of symptomatic vasospasm (90.0% vs 51.7%; P = 0.03). When comparing patients discharged from the hospital without VPS, delayed VPS patients also had higher 6- and 12-month mortality (P = 0.02) and longer EVD clamp trials (P < 0.01) than patients who never required VPS but had an EVD during hospitalization. Delayed hydrocephalus occurred in only 7.8% of patients who passed the initial EVD clamp trial, compared to 14.3% who failed the initial trial and 80.0% who failed 2 or more trials. CONCLUSION: Patients who failed their initial or subsequent EVD clamp trials had a small, but increased risk of developing delayed hydrocephalus ultimately requiring VPS. Additionally, the majority of patients who presented with delayed hydrocephalus also suffered symptomatic vasospasm. These associations should be further explored and validated in a larger prospective study.

Quantitative Modeling of External Ventricular Drain Output to Predict Shunt Dependency in Aneurysmal Subarachnoid Hemorrhage: Cohort Study.

BACKGROUND: Acute hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH); however, attempts to predict shunt-dependent chronic hydrocephalus using clinical parameters have been equivocal. METHODS: Cohort study of aSAH is treated with external ventricular drainage (EVD) placement at our institution, 2001-2016, via logistic regression. EVD-related parameters included mean/total EVD output (days 0-2), EVD days, EVD days ≤ 5 mmHg, and wean/clamp fails. aSAH outcomes assessed included ventriculoperitoneal shunt (VPS) placement, delayed cerebral ischemia (DCI), radiographic infarction (RI), symptomatic vasospasm (SV), age, and aSAH grades. RESULTS: Two hundred and ten aSAH patients underwent EVD treatment for a median 12 days (range 1-54); 85 required VPS (40%). On univariate analysis, EVD output, total EVD days, EVD days ≤ 5 mmHg, and wean/clamp trial failures were significantly associated with VPS placement (p < 0.01 for all parameters). No EVD output parameter demonstrated a significant association with DCI, RI, or SV. On multivariate analysis, EVD output was a significant predictor of VPS placement, after adjusting for age and clinical and radiological grades; the optimal threshold for predicting VPS placement was mean daily output > 204 ml on days 0-2 (OR 2.59, 95% CI 1.31-5.07). Multiple wean failures were associated with unfavorable functional outcome, after adjusting for age, grade, and VPS placement (OR 1.65, 95% CI 1.10-2.47). We developed a score incorporating age, grade and EVD parameters (MAGE) for predicting VPS placement after aSAH. CONCLUSIONS: EVD output parameters and wean/clamp trial failures predicted shunt dependence in an age- and grade-adjusted multivariable model. Early VPS placement may be warranted in patients with MAGE score ≥ 4, particularly following 2 failed wean trials.

Trend in ventricle size during pregnancy and its use for prediction of ventriculoperitoneal shunt in fetal open neural tube defect.

OBJECTIVES: Fetal surgery for repair of open neural tube defect (ONTD) typically results in decreased need for a ventriculoperitoneal shunt (VPS). Our objectives were to determine the trend in ventricle size (VS) during pregnancy and whether VS and change in VS, as assessed by ultrasound, were predictive of the need for VPS in pregnancy with ONTD. METHODS: This was a retrospective analysis of prospectively collected data of consecutive pregnancies with ONTD, evaluated in a single center from January 2012 to May 2018. Two groups were identified: the first consisted of pregnancies that underwent in-utero repair (IUR) and the second those that had postnatal repair (PNR). Penalized B splines were used to determine the trend in VS, across 2-week gestational-age (GA) epochs, between 24 and 36 weeks of gestation. VS at each GA epoch and the change in VS between each GA epoch were compared between the IUR and PNR groups. To determine whether VS at any GA was predictive of VPS, receiver-operating-characteristics (ROC) curves were used and the optimal cut-off at each GA epoch was identified. Univariate analysis and multiple logistic regression were used for further analysis. RESULTS: ONTD was diagnosed in 110 fetuses, of whom 69 underwent IUR and 41 had PNR. Fetuses in the IUR group were more likely to have Chiari II malformation (100.0% vs 82.9%; P < 0.01), lower GA at delivery (34.9 ± 3.2 vs 37.1 ± 2.1 weeks; P < 0.01) and lower rates of VPS within the first year postpartum (36.2% vs 61.0%; P = 0.02) compared with the PNR group. In both groups, VS increased steadily with GA from the initial evaluation to delivery. In the IUR group, there was a significant change in VS between the 24 + 0 to 25 + 6-week and the 26 + 0 to 27 + 6-week epochs (2.3 (95% CI, 0.4-4.1) mm; P = 0.02). There was a positive trend in the change in VS at later GAs, but this was not significant. Although there was no significant change in VS in the PNR group before 30 weeks, there was a positive trend after that time. On multivariate analysis, each week of advancing GA was associated with a mean increase of 0.74 mm in VS (P < 0.0001) in both groups. VS was not associated with the level or type of lesion, but presence of Chiari II malformation was associated with a mean increase of 5.88 mm (P < 0.0001) in VS in both the IUR and PNR groups. VS was modestly predictive of need for VPS in both groups, with area under ROC curves between 0.68 and 0.76 at the different GA epochs. Change in VS between the first and last measurements was also modestly predictive of the need for VPS, with better performance in the PNR group. CONCLUSIONS: VS increased with advancing GA in all fetuses with ONTD, although in the IUR group this increase occurred immediately after fetal surgery and in the PNR group it occurred after 30 weeks of gestation. In-utero surgery was associated with a decreased rate of VPS and was more predictive of need for VPS than was VS. Postnatal factors resulting in increased need for VPS in the PNR group need to be assessed further. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Laparoscopy assisted ventriculoperitoneal shunt placement in children.

BACKGROUND: Placement of ventriculoperitoneal shunts (VPS) can be challenging in children with previous VPS, previous abdominal surgery, or complex abdominal pathology. Laparoscopy can help identify intra-abdominal adhesions and determine the optimal site for insertion of the distal VPS catheter. We analyzed the feasibility and safety of laparoscopy assisted VPS placement (lapVPS) in children. METHODS: A retrospective review from January/2015 to December/2018 was performed. Laparoscopy was performed via a 5 mm trans-umbilical port. Once the optimal entry site was identified, the distal end of the VPS was inserted by Seldinger technique under direct laparoscopic guidance. RESULTS: One hundred ten lapVPS procedures were reviewed. Median age was 1 (IQR 0.3-9.37) year. Fifty-five (50%) patients were <1 year, and 15 (13.6%) were ≤28 days old. The mean age of the neonates was 14.7 (SD 7.6, range 4-28) days, and the mean weight was 3 (SD 0.39, range 2.4-3.7) kg. Thirty-one (28.2%) lapVPS were initial VPS placements, whereas 79 (71.8%) were subsequent VPS placements. Thirty-nine (35.5%) patients had a history of abdominal surgery or complex abdominal pathology. Median operative time was 36 (IQR 28-56) minutes. One hundred seven (97.3%) patients underwent successful lapVPS. Two (1.8%) patients underwent diagnostic laparoscopy, and lapVPS was deemed infeasible due to intraabdominal adhesions. One (0.9%) patient had an intestinal perforation from trocar placement. Three patients developed 5 postoperative complications that required a reoperation. CONCLUSION: Laparoscopy is a valuable tool to assess the suitability of the peritoneal cavity to accommodate a VPS. LapVPS is safe and can be performed in children of all ages. LEVEL OF EVIDENCE: Level IV.

Incidence, diagnostic criteria and outcome following ventriculoperitoneal shunting of idiopathic normal pressure hydrocephalus in a memory clinic population: a prospective observational cross-sectional and cohort study.

OBJECTIVE: To evaluate diagnostic criteria for idiopathic normal pressure hydrocephalus (INPH) among patients with memory impairment, and to estimate the incidence of INPH. DESIGN: Prospective observational cross-section and cohort study of diagnostic accuracy. SETTING: Memory Disorders Clinic following referral by the medical practitioners. PARTICIPANTS: 408 consecutive patients enrolled 2010-2014. OUTCOME MEASURES: Reference diagnostic test was the clinical judgement of an experienced specialist based on the presence of cognitive impairment and/or balance and gait disorders in the presence of dilated ventricles. Mini-Mental State Examination (MMSE), Tinetti balance and gait tests were performed before and 12 months after ventriculoperitoneal shunt surgery. The association between reference diagnosis, clinical and brain CT scan measurements was estimated by multivariate Poisson regression. Triage index diagnostic test scores were calculated from the regression coefficients, with diagnostic thresholds selected using receiver operating characteristic analysis. RESULTS: The presence of balance and/or gait disorders, especially fear of falling, difficulty standing on toes/heals, urinary disturbances, ventriculomegaly with Evans ratio greater than Combined Diagnostic Threshold (0.377-{Maximum width of posterior horns*0.0054}), strongly predict the diagnosis of INPH; while hallucinations and/or delusions and forgetfulness reduce the likelihood of the diagnosis. This triage index test had high sensitivity (95.2%) and specificity (91.7%). 62 of 408 (15%) participants with cognitive impairment had INPH, an incidence of 11.9/100 000/year and 120/100 000/year over 75 years. 96% of participants following shunting, compared with 45% of the non-shunted, improved by over 25% of available measurable improvement in either MMSE or balance/gait scores (51% difference; 95% CI 28% to 74%; p<0.001), and 56% vs 5% improved by over 50% of maximum in both (51% difference; 95% CI 30% to 73%; p<0.001). CONCLUSION: The triage index test score is a simple tool that may be useful for physicians to identify INPH diagnoses and need for referral for shunt surgery, which may improve cognitive, balance and gait functioning.

Primary External Ventricular Drains in the Management of Open Myelomeningocele Repairs in the Neonatal Setting in Ireland

Aim The aim of this study is to outline the role of primary external ventricular drains (EVD) in the management of open myelomeningoceles in the neonatal setting in Ireland. Methods Retrospective cohort study involving all infants who underwent open myelomeningocele repair in a teritary centre in Ireland between January 2009 and April 2016. Medical charts and laboratory data was reviewed on all infants meeting the inclusion criteria. Results One hundred and forty-three neonates underwent open myelomeningocele repair in the 6.5 year period. EVD were inserted at the time of primary wound closure in 19 cases (13%). EVD were used to aid in wound closure and as a primary method of cerebrospinal fluid (CSF) diversion. They remained in place for a median of 8 days, ranging from 1-22 days. All EVD, apart from one, in our series were replaced by a ventricular-peritoneal (VP) shunt at some stage. Conclusion EVD were used in 13% of cases of open myelomeningocele repairs from Jan 2009-Apr 2016 as a primary measure to aid in management. Compared to the cohort in whom an EVD was not inserted at the time of surgery, there was a decrease in the rate of infections. However, there was an increased rate of wound dehiscence/leak and a later need for VP shunt insertion.

Autologous Bone Cranioplasty: A Retrospective Comparative Analysis of Frozen and Subcutaneous Bone Flap Storage Methods.

OBJECTIVE: The use of autologous bone for cranioplasty offers superior cosmesis and cost-effectiveness compared with synthetic materials. The choice between 2 common autograft storage mechanisms (subcutaneous vs. frozen) remains controversial and dictated by surgeon preference. We compared surgical outcomes after autologous bone cranioplasty between patients with cryopreserved and subcutaneously stored autografts. METHODS: Ten-year retrospective comparative analysis of patients undergoing cranioplasty with autologous bone stored subcutaneously or frozen at a tertiary academic medical center. RESULTS: Ninety-four patients were studied, with 34 (36.2%) bone flaps stored subcutaneously and 59 (62.8%) frozen. The 2 groups were similar in demographics, comorbidities, and craniectomy indication, with only body mass index and race differing statistically. The mean operation time was greater within the subcutaneous group (P < 0.001), which also had a greater number of ventriculoperitoneal shunt (VPS) placements (P = 0.02). There were no significant differences in complications, readmissions, unplanned reoperations, or length of stay between the 2 groups. VPS placement during cranioplasty increased length of stay (P < 0.001), and placement prior to cranioplasty increased both length of stay (P = 0.009) and incidence of hospital-acquired infection (P = 0.03). CONCLUSIONS: Subcutaneous and frozen storage of autologous bone result in similar surgical risk profiles. Cryopreservation may be preferred because of shorter operation time and avoidance of complications with the abdominal pocket, whereas the portability of subcutaneous storage remains favorable for patients undergoing cranioplasty at a different institution. VPS placement prior to cranioplasty should be avoided, if possible, due to the increased risk of hospital-acquired infection.

Ventriculo-peritoneal shunting is a safe and effective treatment for idiopathic intracranial hypertension.

PURPOSE: To determine the outcome of ventriculo-peritoneal shunts as a treatment for idiopathic intracranial hypertension (IIH) Materials and Methods: Retrospective case series of 28 patients with IIH and evidence of raised intracranial pressure (ICP) who underwent shunt insertion. Patients were identified from a prospectively updated operative database. A case-notes review was performed and data on type of shunt, pre- and post-operative symptoms, ophthalmological findings and post-operative complications were recorded. RESULTS: All patients had symptoms of IIH that had failed medical management. Twelve patients had previous lumbo-peritoneal shunts and 2 patients had previous venous sinus stents. All patients had evidence of raised ICP as papilloedema and raised CSF pressure on lumbar puncture. Twenty-seven patients received a ventriculo-peritoneal shunt and 1 patient a ventriculo-atrial shunt. Twenty-six patients received Orbis Sigma Valves and 2 patients Strata valves. At follow-up all patients (100%) had improvement/resolution of papilloedema, 93% had improved visual acuity and 84% had improved headaches. Mean time to last follow-up was 15 (range 4-96) months. Complications occurred in 3 patients (11%): 2 patients required revision of their peritoneal catheters and 1 patient had an anti-siphon device inserted. CONCLUSIONS: Previous literature reported a ventricular shunt revision rate of 22-42% in the management of IIH. We demonstrate ventriculo-peritoneal shunts to be an effective treatment with a revision rate of 11% compared to the previously reported 22-42%.

Management of Choroid Plexus Tumors in Infants and Young Children Up to 4 Years of Age: An Institutional Experience.

BACKGROUND: Choroid plexus tumors (CPTs) are rare tumors characterized by papillary and intraventricular growth. The young age of presentation of such tumors, especially in infants, and the lack of consensus on adjuvant therapy in case of atypical choroid plexus papilloma (aCPP) and choroid plexus carcinoma (CPC) create dilemma for the management of such tumors. We discuss the presentation, management, complications, and outcome in 15 patients (children 4 years of age and younger) and review pertinent literature. METHODS: We retrospectively analyzed the case records of all patients with CPTs who were operated in our institute from January 2010 to March 2018. We found 15 patients in the age group of 0-4 years of age. The variables analyzed include age, sex, presentation, location, surgical approach, extent of resection, intraoperative blood loss, percentage of blood loss, blood transfused, histopathology, postoperative complications, and outcome. Images were obtained from picture archiving and communication system, and patient details and follow-up were obtained from discharge summary, operative notes, and hospital records. RESULTS: Ten patients had choroid plexus papilloma (CPP), 2 patients had aCPP, and 3 patients had CPC. The mean age was 15.2 months, whereas the median age was 8 months (range, 40 days-4 years). The mean blood loss was 329 mL, whereas the median blood loss was 175 mL. There were a total of 5 deaths, including 3 patients with CPC and 1 each with aCPP and CPP. CONCLUSIONS: CPTs are challenging tumors in infants and very young children because of the potential for massive blood loss. CPP is associated with lesser blood loss and favorable outcome compared with aCPP and CPC. Massive blood loss in CPC and aCPP can be life threatening as has been shown in our series. CPC has a rapid proliferation potential as shown in one of our cases. Attempts at decreasing vascularization of such tumors should be made by various methods, including preoperative embolization and neoadjuvant chemotherapy; however, a consensus on this is lacking.

The Value of Computed Tomography Imaging of the Head After Ventriculoperitoneal Shunt Surgery in Adults.

BACKGROUND: Patients with a ventriculoperitoneal shunt for hydrocephalus often undergo multiple follow-up computed tomography (CT) scans of the head, increasing the risk for long-term effects of ionizing radiation. The purpose of our study was to evaluate the necessity as a routine diagnostic procedure and cost analysis of routine postoperative CT scan of the head after ventriculoperitoneal shunt surgery. METHODS: In this study, we comprised adults with ventriculoperitoneal shunt operations who underwent early CT scans within 48 hours postoperatively. We reviewed the correlation between revision surgery rate and the experience of surgeons who performed surgery and provided a cost analysis. RESULTS: In total, 479 surgeries were performed in 439 patients. Early revision surgery was performed in 11 (2.3%) patients. Reason for revision surgery was malposition in 9 cases and intracerebral hemorrhage in 2 patients. There was no significant correlation between the surgeon's experience and the rate of revision surgery. Placement of the ventricular catheter via an approach other than a standard right or left frontal burr hole resulted in risk of need for surgical shunt revision (P ≥ 0.002, odds ratio 54, confidence interval 13.5-223). A total of 468 CT scans of the head revealed a normal finding; thus, ∼$562,000 could be saved by omitting postoperative head CT scans. CONCLUSIONS: Routine postoperative head CT scans after fentriculoperitoneal shunting are not necessary in all cases. The reduction of exposure to ionization radiation and the beneficial economic factor are main advantages.

Is Shunt Evaluation Useful in Children With Intraventricular Shunts With Seizures?

BACKGROUND: Seizures are a common presenting symptom to the emergency department (ED) in children with intraventricular shunts (IVS). The incidence of shunt malfunction and the yield of imaging studies in children with IVS presenting with seizures is unknown. OBJECTIVES: We assessed the utility and diagnostic yield of evaluation for shunt malfunction in patients with IVS with seizure and identified clinical predictors for shunt malfunction in these children. METHODS: We performed a retrospective review of children aged zero to 21 years of age with IVS who presented to the ED with seizure between 2011 and 2015. Demographic, clinical, laboratory and radiological data were collected. Shunt malfunction was diagnosed based on whether a shunt revision was performed during the hospitalization. RESULTS: We evaluated 408 ED visits (median age: six years [IQR: 3, 11], males 61.5%) for IVS with seizures. Few visits were for first seizure (37; 9.1%) or for status epilepticus (46 visits; 11.3%). Computerized tomography head was performed in 318 patients (95.2%), of which 32 scans (10.6%) were suggestive of shunt malfunction. A shunt series was performed in 302 (90.4%) and was suggestive of shunt malfunction in eight (2.6%) patients. Shunt malfunction was diagnosed in 40 of 408 visits (9.8%). Only a history of multiple (≥3) shunt revisions was significantly associated with shunt malfunction. There was no association between number, type, or prior history of seizures and shunt malfunction. CONCLUSION: Our study demonstrates a low yield of imaging studies for the evaluation of shunt malfunction in children with IVS with seizures, and shunt malfunction is an uncommon cause of seizures in these children.

Treating Pediatric Hydrocephalus at the Neurosurgery Education and Development Institute: The Reality in the Zanzibar Archipelago, Tanzania.

BACKGROUND: Pediatric hydrocephalus is a health burden for East African countries, with an estimated incidence of 6000 new cases per year. The objective of this study is to describe the epidemiology and surgical outcomes of patients treated for pediatric hydrocephalus in the single neurosurgical center of Zanzibar. METHODS: From December 2016 to December 2017, we prospectively collected data on all patients admitted with the diagnosis of hydrocephalus. Information was gathered regarding demographics, maternal health, preoperative imaging, surgical procedures, and postsurgical complications. RESULTS: We collected data on 63 patients. Average age was 203 days, and gender was 49.2% female and 50.8% male. All mothers of patients attended an antenatal clinic for routine screening during pregnancy. Folic acid prophylaxis was used by 9.5% of the mothers during pregnancy. At the first visit, 46.0% of patients presented with signs of infection, 20.6% with congenital abnormalities, and 20.6% with seizures. Regarding etiology of hydrocephalus, 22.2% of all cases were uncertain; 20.6% were associated with neural tube defects; 39.7% were postinfectious hydrocephalus; 3.2% were aqueduct stenosis; 4.8% were associated with brain tumor; and 9.6% were malformative. We performed 7 endoscopic third ventriculostomies and placed 40 ventriculoperitoneal shunts. The complication rate at follow-up was 12.5%. CONCLUSIONS: It seems that hydrocephalus in Zanzibar has similar causes, progression, and complication rates to previous reports from other African hospitals. Further studies of postinfectious hydrocephalus need to be conducted because recent findings suggest that it is a potentially preventable cause of the disease.