Surgical Indications and Operative Results of Lumbosubarachnoid-Lumboepidural Shunting in 29 Patients with Idiopathic Normal Pressure Hydrocephalus under Local Anesthesia.

This study consisted of 29 patients with idiopathic normal pressure hydrocephalus (iNPH) who underwent lumbosubarachnoid-lumboepidural (L-L) shunting under local anesthesia in accordance with our surgical indications of L-L shunting. (1) CSF absorption within the lumbar epidural space and shunt clearance were confirmed in all patients after operation. (2) Shunt responders (R) were 25 of 29 cases (86.2%) 3 months after surgery. Among the R, symptom exacerbation was confirmed in three patients (12%) within the follow-up period (mean, 25.1 months). In each of these patients, shunt function were maintained and remained unchanged even with pressure resetting, the cause being an intracranial/extracranial disease other than iNPH. (3) The initial pressure setting for this method was 8 cmH2O, with gradual change to higher pressures, such that the setting for Patient 11 and thereafter became 20 cmH2O. (4) As postsurgical complications, subcutaneous cerebral spinal fluid collection (SCC) was confirmed in five patients (17.2%). In high-pressure resetting and follow-up observation, SCC was not observed in all patients. Epidural catheter displacement was confirmed in three patients (10.3%). No recurrence was noted after the secure fixation of the catheter at the fascia insertion portion and 2 days' postsurgical bed rest. Hence, L-L shunting is an effective shunt therapy for iNPH.

Evaluation of an institutional guideline for the treatment of cerebrospinal fluid shunt-associated infections.

BACKGROUND: Cerebrospinal fluid (CSF) shunt-associated infection is one of the most frequent complications of CSF shunt surgery. We evaluated our institutional guideline for the treatment of shunt-associated infections. METHODS: We retrospectively analysed all 92 episodes of shunt-associated infections in 78 patients treated in our institution from 2002 to 2008. All patients underwent urgent surgery, i.e. removal of the complete shunt hardware or externalisation of the distal tubing in cases with an infection restricted to the distal shunt (10 %), placement of an external ventricular drainage as necessary and antibiotic therapy. Standard empirical first-line antibiotic treatment consisted of a combination of flucloxacillin and cefuroxime. RESULTS: We observed 38 % early (<1 month after shunt surgery) and 20 % late infections (> 1 year after shunt placement). Coagulase-negative staphylococci (CoNS) were isolated in 38 %. In 38 % no pathogens could be isolated. Of cases with a first shunt infection, 58 % were initially treated with flucloxacillin/cefuroxime. Only 53 % of all infections were treated successfully with the first course of antibiotics. Only 51 % of bacterial isolates were sensitive to empirical first-line antibiotics. Twenty percent of infections caused by sensitive bacterial isolates nevertheless required second-line antibiotic therapy. CONCLUSIONS: Urgent surgery for shunt removal and antibiotic therapy will usually cure a shunt-associated infection. The choice of antibiotics should reflect the spectrum of pathogens seen at one's institution, paying particular attention to the role of CoNS isolates, and in vitro sensitivity testing results.

[Abscess of the abdominal wall following penetration of the descending colon: a rare complication of a ventriculoperitoneal shunt].

A case of abscess of the abdominal wall associated with a ventriculoperitoneal (V-P) shunt following penetration into the descending colon is reported. A 49-year-old male was diagnosed as having hypertensive intracerebellar hematoma with hydrocephalus, and he was treated by V-P shunt. One year later he experienced left hypochondrial pain with rebound tenderness during a period of one week. He was doing well until 4 years and 10 months after, when barium enema examination and colonoscopy incidentally demonstrated that the abdominal catheter had penetrated into the descending colon. However, he had no symptoms. He remained in good health during a period of observation. A year later he was readmitted to our department with an abscess of the abdominal wall. Plain radiograph of the abdomen demonstrated disconnection of the shunt catheter and it was thought that the abdominal catheter had been passed via the rectum. At operation a subcutaneous abscess was found and cultures grew proteus mirabilis. We discussed the mechanism of the developing of the abscess on the abdominal wall following penetration of the bowel. It is believed that abscess of the abdominal wall may occur due to spontaneous extraction of a previously inserted shunt catheter which has penetrated into the bowel.

Rifampin therapy of Staphylococcus epidermidis. Use in infections from indwelling artificial devices.

Rifampin was added to existing antibiotic regimens in two patients with Staphylococcus epidermidis infections; one patient had prosthetic valve endocarditis and the other had an infection of a CSF shunt. The addition of rifampin increased serum or CSF bactericidal titers 16-fold or greater and was correlated with a favorable clinical response. The results of tests for tube-dilution antibiotic susceptibility showed rifampin to be the most active of all antibiotics tested against the patients' organisms. The combinations of gentamicin sulfate, nafcillin sodium, or vancomycin hydrochloride with rifampin prevented the emergence of rifampin resistance in vitro and promoted enhanced killing when compared with either antibiotic alone.