Prognostic Nomogram of Predictors for Shunt-Dependent Hydrocephalus in Patients with Aneurysmal Subarachnoid Hemorrhage Receiving External Ventricular Drain Insertion: A Single-Center Experience and Narrative Review.

OBJECTIVE: This study aimed to create a prediction model with a radiographic score, serum, and cerebrospinal fluid (CSF) values for the occurrence of shunt-dependent hydrocephalus (SDHC) in patients with aneurysmal subarachnoid hemorrhage (aSAH) and to review and analyze literature related to the prediction of the development of SDHC. METHODS: Sixty-three patients with aSAH who underwent external ventricular drain insertion were included and separated into 2 subgroups: non-SDHC and SDHC. Patient characteristics, computed tomography scoring system, and serum and CSF parameters were collected. Multivariate logistic regression was conducted to illustrate a nomogram for determining the predictors of SDHC. Furthermore, we sorted and summarized previous meta-analyses for predictors of SDHC. RESULTS: The SDHC group had 42 cases. Stepwise logistic regression analysis revealed 3 independent predictive factors associated with a higher modified Graeb (mGraeb) score, lower level of estimated glomerular filtration rate group, and lower level of CSF glucose. The nomogram, based on these 3 factors, was presented with significant predictive performance (area under curve = 0.895) for SDHC development, compared with other scoring systems (AUC = 0.764-0.885). In addition, a forest plot was generated to present the 12 statistically significant predictors and odds ratio for correlations with the development of SDHC. CONCLUSIONS: First, the development of a nomogram with combined significant factors had a good performance in estimating the risk of SDHC in primary patient evaluation and assisted in clinical decision making. Second, a narrative review, presented with a forest plot, provided the current published data on predicting SDHC.

Unexpected Decrease in Shunt Surgeries Performed during the Shelter-in-Place Period of the COVID-19 Pandemic.

BACKGROUND: It is expected that the incidence of cerebrospinal fluid (CSF) shunt malfunctions would remain unchanged during the shelter-in-place period related to the COVID-19 pandemic. OBJECTIVE: To examine the number of shunt surgeries performed in a single institution during this time interval in comparison to equivalent periods in past years. METHODS: The numbers of elective and emergent/urgent shunt surgeries performed at a single institution were queried for a 28-d period starting on the third Monday of March, between years 2015 and 2020. These were further stratified by how they presented as well as the type of surgery performed. RESULTS: During the 28-d period of interest, in the years between 2015 and 2020, there was a steady increase in the number of shunt surgeries performed, with a maximum of 64 shunt surgeries performed in 2019. Of these, approximately 50% presented in urgent fashion in any given year. In the 4-wk period starting March 16, 2020, a total of 32 shunt surgeries were performed, with 15 of those cases presenting from the outpatient setting in emergent/urgent fashion. For the surgeries performed, there was a statistically significant decrease in the number of revision shunt surgeries performed. CONCLUSION: During the 2020 COVID-19 pandemic, there was an unexpected decrease in the number of shunt surgeries performed, and particularly in the number of revision surgeries performed. This suggests that an environmental factor related to the pandemic is altering the presentation rate of shunt malfunctions.

Impact of COVID-19 on a Neurosurgical Service: Lessons from the University of California San Diego.

BACKGROUND: The institution-wide response of the University of California San Diego Health system to the 2019 novel coronavirus disease (COVID-19) pandemic was founded on rapid development of in-house testing capacity, optimization of personal protective equipment usage, expansion of intensive care unit capacity, development of analytic dashboards for monitoring of institutional status, and implementation of an operating room (OR) triage plan that postponed nonessential/elective procedures. We analyzed the impact of this triage plan on the only academic neurosurgery center in San Diego County, California, USA. METHODS: We conducted a de-identified retrospective review of all operative cases and procedures performed by the Department of Neurosurgery from November 24, 2019, through July 6, 2020, a 226-day period. Statistical analysis involved 2-sample z tests assessing daily case totals over the 113-day periods before and after implementation of the OR triage plan on March 16, 2020. RESULTS: The neurosurgical service performed 1429 surgical and interventional radiologic procedures over the study period. There was no statistically significant difference in mean number of daily total cases in the pre-versus post-OR triage plan periods (6.9 vs. 5.8 mean daily cases; 1-tail P = 0.050, 2-tail P = 0.101), a trend reflected by nearly every category of neurosurgical cases. CONCLUSIONS: During the COVID-19 pandemic, the University of California San Diego Department of Neurosurgery maintained an operative volume that was only modestly diminished and continued to meet the essential neurosurgical needs of a large population. Lessons from our experience can guide other departments as they triage neurosurgical cases to meet community needs.

Trends in the Surgical Treatment of Pseudotumor Cerebri Syndrome in the United States.

Importance: Optic nerve sheath fenestration (ONSF) and cerebrospinal fluid shunting are sometimes used to treat pseudotumor cerebri syndrome (PTCS), but their use patterns are unknown. Objectives: To investigate the frequency of surgical PTCS treatment in the United States and to compare patients undergoing ONSF with those treated with shunting. Design, Setting, and Participants: This was a retrospective longitudinal cross-sectional study. Inpatient data were obtained from the National Inpatient Sample (NIS), and outpatient surgical center data were obtained from the National Survey of Ambulatory Surgery (NSAS) and National Hospital Ambulatory Medical Care Survey (NHAMCS). Included in the analysis were 10 720 patients aged 18 to 65 years with a diagnosis code for PTCS, excluding venous thrombosis and other causes of intracranial hypertension. Time trends were explored and logistic regression was used to measure differences according to age, race/ethnicity, sex, Elixhauser comorbidity index, and other patient and hospital characteristics. Data analysis was performed from March 31 to October 7, 2020. Exposure: Treatment for PTCS, excluding venous thrombosis and other causes of intracranial hypertension. Main Outcomes and Measures: Annual number of PTCS-related admissions, ONSFs, and shunt procedures from 2002-2016. Patient and hospital-level characteristics of patients with PTCS undergoing ONSF or shunting were compared. Results: Between 2010 and 2016, 297 ONSFs were performed and 10 423 shunts were placed as treatment for PTCS. The procedures were most commonly performed in individuals aged 26 to 35 years (39.4%), and 9920 (92.4%) of the surgically treated patients were women. ONSF was more common among younger patients (eg, adjusted odds ratio [AOR] for patients ≥46 years vs those 18-25 years, 0.22; 95% CI, 0.08-0.61) and in Black, Hispanic, or other minority populations (AOR, 2.37; 95% CI, 1.31-4.30) and less common in the South (AOR, 0.34; 95% CI, 0.13-0.88) and West (AOR, 0.15; 95% CI, 0.04-0.58) compared with the Northeast. Total PTCS-related hospitalizations increased from 6081 (95% CI, 5137-7025) in 2002 to 18 020 (95% CI, 16 607-19 433) in 2016. Shunting increased from 2002 to 2011 and subsequently plateaued and declined. ONSF was used much less frequently, and use has not increased. No instances of outpatient ONSF or shunting for PTCS were recorded in the NSAS or NHAMCS databases. Conclusions and Relevance: This study's findings suggest that shunting is more common than ONSF and that the use gap has widened as shunting has increased. However, because overall PTCS-related hospitalizations have increased even more rapidly, the percentage of inpatients with PTCS undergoing surgery has decreased. These trends may reflect changes in medical treatment practices and outcomes or growing limitations in access to ophthalmic surgical expertise.

Stereotactic radiosurgery for central neurocytomas: an international multicenter retrospective cohort study.

OBJECTIVE: Central neurocytomas (CNs) are uncommon intraventricular tumors, and their rarity renders the risk-to-benefit profile of stereotactic radiosurgery (SRS) unknown. The aim of this multicenter, retrospective cohort study was to evaluate the outcomes of SRS for CNs and identify predictive factors. METHODS: The authors retrospectively analyzed a cohort of patients with CNs treated with SRS at 10 centers between 1994 and 2018. Tumor recurrences were classified as local or distant. Adverse radiation effects (AREs) and the need for a CSF shunt were also evaluated. RESULTS: The study cohort comprised 60 patients (median age 30 years), 92% of whom had undergone prior resection or biopsy and 8% received their diagnosis based on imaging alone. The median tumor volume and margin dose were 5.9 cm3 and 13 Gy, respectively. After a median clinical follow-up of 61 months, post-SRS tumor recurrence occurred in 8 patients (13%). The 5- and 10-year local tumor control rates were 93% and 87%, respectively. The 5- and 10-year progression-free survival rates were 89% and 80%, respectively. AREs were observed in 4 patients (7%), but only 1 was symptomatic (2%). Two patients underwent post-SRS tumor resection (3%). Prior radiotherapy was a predictor of distant tumor recurrence (p = 0.044). Larger tumor volume was associated with pre-SRS shunt surgery (p = 0.022). CONCLUSIONS: Treatment of appropriately selected CNs with SRS achieves good tumor control rates with a reasonable complication profile. Distant tumor recurrence and dissemination were observed in a small proportion of patients, which underscores the importance of close post-SRS surveillance of CN patients. Patients with larger CNs are more likely to require shunt surgery before SRS.

Perinatal events predicting retinopathy of prematurity in extremely pre-term infants.

BACKGROUND: Extremely preterm infants are peculiar in regard to their risk of retinopathy of prematurity (ROP). In this study, we aim to study insults that may affect extremely preterm infants, including prenatal, at birth, and postnatal insults and their effect on the development of ROP. METHODS: This study used the data from Prematurity and Respiratory Outcomes Program (PROP). All included infants with a gestational age of 23 0/7 to 28 6/7 weeks using best obstetrical estimate. We included stressful events and/or modifiable variables that may affect the normal development. We used multiple regression analysis in our statistical analysis. RESULTS: We included a total of 751 infants in our study. The mean birth weight for the included sample was 915.1 (±232.94) grams. 391 (52.1%) Infants were diagnosed with ROP. We found a significant negative correlation between ROP development and birth weight (p < 0.001), with a correlation coefficient of - 0.374. We found that the need for prophylactic indomethacin (OR 1.67), the occurrence of air leaks (OR: 2.35), ventilator-associated pneumonia (OR: 2.01), isolated bowel perforations (OR: 3.7), blood culture-proven sepsis (OR: 1.5), other infections (OR: 1.44), and receiving ventricular shunt (OR: 2.9) are significantly associated with the development of ROP. CONCLUSIONS: We believe this study included the largest number of factors studied in the largest sample of extremely premature infants. We recommend a screening program for extremely preterm infants that takes into account a scoring system with higher scores for complicated condition.

Factors Associated With Ambulation in Myelomeningocele: A Longitudinal Study From the National Spina Bifida Patient Registry.

OBJECTIVE: Evidence is limited regarding clinical factors associated with ambulation status over the lifespan of individuals with myelomeningocele. We used longitudinal data from the National Spina Bifida Patient Registry to model population-level variation in ambulation over time and hypothesized that effects of clinical factors associated with ambulation would vary by age and motor level. DESIGN: A population-averaged generalized estimating equation was used to estimate the probability of independent ambulation. Model predictors included time (age), race, ethnicity, sex, insurance, and interactions between time, motor level, and the number of orthopedic, noncerebral shunt neurosurgeries, and cerebral shunt neurosurgeries. RESULTS: The study cohort included 5371 participants with myelomeningocele. A change from sacral to low-lumbar motor level initially reduced the odds of independent ambulation (OR = 0.24, 95% CI = 0.15-0.38) but became insignificant with increasing age. Surgery count was associated with decreased odds of independent ambulation (orthopedic: OR = 0.65, 95% CI = 0.50-0.85; noncerebral shunt neurosurgery: OR = 0.65, 95% CI = 0.51-0.84; cerebral shunt: OR = 0.90, 95% CI = 0.83-0.98), with increasing effects seen at lower motor levels. CONCLUSIONS: Our findings suggest that effects of several commonly accepted predictors of ambulation status vary with time. As the myelomeningocele population ages, it becomes increasingly important that study design account for this time-varying nature of clinical reality. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Describe general trends in ambulation status by age in the myelomeningocele population; (2) Recognize the nuances of cause and effect underlying the relationship between surgical intervention and ambulation status; (3) Explain why variation of clinical effect over time within myelomeningocele population matters. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Predicting Development of Alzheimer's Disease in Patients with Shunted Idiopathic Normal Pressure Hydrocephalus.

BACKGROUND: Idiopathic normal pressure hydrocephalus (iNPH) patients often develop Alzheimer's disease (AD) related brain pathology. Disease State Index (DSI) is a method to combine data from various sources for differential diagnosis and progression of neurodegenerative disorders. OBJECTIVE: To apply DSI to predict clinical AD in shunted iNPH-patients in a defined population. METHODS: 335 shunted iNPH-patients (median 74 years) were followed until death (n = 185) or 6/2015 (n = 150). DSI model (including symptom profile, onset age of NPH symptoms, atrophy of medial temporal lobe in CT/MRI, cortical brain biopsy finding, and APOE genotype) was applied. Performance of DSI model was evaluated with receiver operating characteristic (ROC) curve analysis. RESULTS: A total of 70 (21%) patients developed clinical AD during median follow-up of 5.3 years. DSI-model predicted clinical AD with moderate effectiveness (AUC = 0.75). Significant factors were cortical biopsy (0.69), clinical symptoms (0.66), and medial temporal lobe atrophy (0.66). CONCLUSION: We found increased occurrence of clinical AD in previously shunted iNPH patients as compared with general population. DSI supported the prediction of AD. Cortical biopsy during shunt insertion seems indicated for earlier diagnosis of comorbid AD.

Current epidemiology of cerebrospinal fluid shunt surgery in the UK and Ireland (2004-2013).

OBJECTIVES: To determine current epidemiology and clinical characteristics of cerebrospinal fluid (CSF) shunt surgery, including revisions. METHODS: A retrospective, multicentre, registry-based study was conducted based on 10 years' data from the UK Shunt Registry, including primary and revision shunting procedures reported between 2004 and 2013. Incidence rates of primary shunts, descriptive statistics and shunt revision rates were calculated stratified by age group, geographical region and year of operation. RESULTS: 41 036 procedures in 26 545 patients were submitted during the study period, including 3002 infants, 4389 children and 18 668 adults. Procedures included 20 947 (51.0%) primary shunt insertions in 20 947 patients, and 20 089 (49.0%) revision procedures. Incidence rates of primary shunt insertions for infants, children and adults were 39.5, 2.4 and 3.5 shunts per 100 000 person-years, respectively. These varied by geographical subregion and year of operation. The most common underlying diagnoses were perinatal intraventricular haemorrhage (35.3%) and malformations (33.9%) in infants, tumours (40.5%) and malformations (16.3%) in children, and tumours (24.6%), post-haemorrhagic hydrocephalus (16.2%) and idiopathic normal pressure hydrocephalus (14.2%) in adults. Ninety-day revision rates were 21.9%, 18.6% and 12.8% among infants, children and adults, respectively, while first-year revision rates were 31.0%, 25.2% and 17.4%. The main reasons for revision were underdrainage and infection, but overdrainage and mechanical failure continue to pose problems. CONCLUSIONS: Our report informs patients, carers, clinicians, providers and commissioners of healthcare, researchers and industry of the current epidemiology of shunting for CSF disorders, including the potential risks of complications and frequency of revision.

Neurological outcomes by mode of delivery for fetuses with open neural tube defects: a systematic review and meta-analysis.

BACKGROUND: Controversy exists regarding the optimal mode of delivery for fetuses with open neural tube defects. OBJECTIVE: To compare neurological outcomes among infants with open neural tube defects who underwent vaginal compared with caesarean delivery. SEARCH STRATEGY: Electronic databases MEDLINE, EMBASE, Scopus, and Clinicaltrials.gov were searched from inception to November 2017. SELECTION CRITERIA: Eligible studies included observational or randomised studies comparing vaginal and caesarean delivery in pregnancies with fetal open neural tube defects who did not undergo prenatal repair. DATA COLLECTION AND ANALYSIS: Two reviewers independently reviewed abstracts and full-text articles. Outcomes were compared between vaginal and caesarean delivery and prelabour caesarean versus exposure to labour. The primary outcome was motor-anatomic level difference. Secondary outcomes included shunt requirement, sac disruption, meningitis, and ambulation at 2 years. Meta-analysis was performed and mean difference or odds ratios with 95% CI were calculated. MAIN RESULTS: Of 201 abstracts identified in the primary search, nine studies (672 women) met the eligibility criteria. Comparing vaginal and caesarean delivery, there was no significant difference in motor-anatomic level difference (mean difference -0.10, 95% CI -0.58 to 0.38; I2  = 57%). The vaginal delivery group was less likely to require a shunt or have sac disruption [odds ratio (OR) 0.37, 95% CI 0.14-0.95 and OR 0.46, 95% CI 0.23-0.90, respectively]. Comparisons by prelabour caesarean versus exposure to labour showed no significant difference in motor-anatomic level difference (OR 1.29, 95% CI 0.63-3.21) or ambulation at 2 years (OR 2.13, 95% CI 0.35-13.12). CONCLUSION: Caesarean delivery was not associated with improved neurological outcomes among fetuses with open neural tube defects. TWEETABLE ABSTRACT: Available evidence does not support routine caesarean delivery for fetuses with open neural tube defects.

The expanding burden of idiopathic intracranial hypertension.

OBJECTIVE: To quantify the hospital burden and health economic impact of idiopathic intracranial hypertension. METHODS: Hospital Episode Statistics (HES) national data was extracted between 1st January 2002 and 31st December 2016. All those within England with a diagnosis of idiopathic intracranial hypertension were included. Those with secondary causes of raised intracranial pressure such as tumours, hydrocephalus and cerebral venous sinus thrombosis were excluded. RESULTS: A total of 23,182 new IIH cases were diagnosed. Fifty-two percent resided in the most socially deprived areas (quintiles 1 and 2). Incidence rose between 2002 and 2016 from 2.3 to 4.7 per 100,000 in the general population. Peak incidence occurred in females aged 25 (15.2 per 100,000). 91.6% were treated medically, 7.6% had a cerebrospinal fluid diversion procedure, 0.7% underwent bariatric surgery and 0.1% had optic nerve sheath fenestration. Elective caesarean sections rates were significantly higher in IIH (16%) compared to the general population (9%), p < 0.005. Admission rates rose by 442% between 2002 and 2014, with 38% having repeated admissions in the year following diagnosis. Duration of hospital admission was 2.7 days (8.8 days for those having CSF diversion procedures). Costs rose from £9.2 to £50 million per annum over the study period with costs forecasts of £462 million per annum by 2030. CONCLUSIONS: IIH incidence is rising (by greater than 100% over the study), highest in areas of social deprivation and mirroring obesity trends. Re-admissions rates are high and growing yearly. The escalating population and financial burden of IIH has wide reaching implications for the health care system.

Clinical evaluation and surveillance imaging of children with myelomeningocele and shunted hydrocephalus: a follow-up study.

OBJECTIVEThe majority of children with myelomeningocele undergo implantation of CSF shunts. The efficacy of adding surveillance imaging to clinical evaluation during routine follow-up as a means to minimize the hazard associated with future shunt failure has not been thoroughly studied.METHODSA total of 300 spina bifida clinic visits during the calendar years between 2012 and 2016 were selected for this study (defined as the index clinic visit). Each index visit was preceded by a 6-month period during which no shunt evaluation of any kind was performed. At the index clinic visit, all patients were evaluated by a neurosurgeon. Seventy-four patients underwent previously scheduled surveillance CT or shunt series scans in addition to clinical evaluation (surveillance imaging group), and 226 patients did not undergo surveillance imaging (clinical evaluation group). Subsequent unexpected events, defined as emergency department visits, caregiver-requested clinic visits, and shunt revision surgeries were reviewed. The timing and likelihood of an unexpected event in each of the 2 groups were compared using Cox proportional hazard survival analysis. The rate of shunt revision surgery in the follow-up period as well as the associated outcomes and rate of complications were analyzed.RESULTSThe clinical characteristics of the 2 groups were similar. In the clinical evaluation group, 4 of 226 (1.8%) patients underwent shunt revision based on clinical findings during the index visit, compared to 8 of 74 (10.8%) patients in the surveillance imaging group who underwent shunt revision based on clinical and imaging findings at that visit (p < 0.05). In the subsequent follow-up period, there were 74 unexpected events resulting in 10 shunt revisions in the clinical evaluation group, for an event rate of 33% and operation rate of 13.5%. In the surveillance imaging group there were 23 unexpected events resulting in 2 shunt revisions, for an event rate of 34.8% and an operation rate of 8.7%; neither difference was statistically significant. The complication rate for shunt revision surgery was also not different between the groups.CONCLUSIONSObtaining predecided, routine surveillance imaging in children with myelomeningocele and shunted hydrocephalus resulted in more shunt revisions in asymptomatic patients. For patients who had negative results on surveillance imaging, the rate of shunt revision in the follow-up period was not significantly decreased compared to patients who underwent clinical examination only at the index visit.

Post hemorrhagic hydrocephalus and neurodevelopmental outcomes in a context of neonatal intraventricular hemorrhage: an institutional experience in 122 preterm children.

BACKGROUND: Intraventricular hemorrhage (IVH) is a frequent complication in extreme and very preterm births. Despite a high risk of death and impaired neurodevelopment, the precise prognosis of infants with IVH remains unclear. The objective of this study was to evaluate the rate and predictive factors of evolution to post hemorrhagic hydrocephalus (PHH) requiring a shunt, in newborns with IVH and to report their neurodevelopmental outcomes at 2 years of age. METHODS: Among all preterm newborns admitted to the department of neonatalogy at Rouen University Hospital, France between January 2000 and December 2013, 122 had an IVH and were included in the study. Newborns with grade 1 IVH according to the Papile classification were excluded. RESULTS: At 2-year, 18% (n = 22) of our IVH cohort required permanent cerebro spinal fluid (CSF) derivation. High IVH grade, low gestational age at birth and increased head circumference were risk factors for PHH. The rate of death of IVH was 36.9% (n = 45). The rate of cerebral palsy was 55.9% (n = 43) in the 77 surviving patients (49.4%). Risk factors for impaired neurodevelopment were high grade IVH and increased head circumference. CONCLUSION: High IVH grade was strongly correlated with death and neurodevelopmental outcome. The impact of an increased head circumference highlights the need for early management. CSF biomarkers and new medical treatments such as antenatal magnesium sulfate have emerged and could predict and improve the prognosis of these newborns with PHH.

Treated hydrocephalus in individuals with myelomeningocele in the National Spina Bifida Patient Registry.

OBJECTIVEAlthough the majority of patients with myelomeningocele have hydrocephalus, reported rates of hydrocephalus treatment vary widely. The purpose of this study was to determine the rate of surgical treatment for hydrocephalus in patients with myelomeningocele in the National Spina Bifida Patient Registry (NSBPR). In addition, the authors explored the variation in shunting rates across NSBPR institutions, examined the relationship between hydrocephalus, and the functional lesion level of the myelomeningocele, and evaluated for temporal trends in rates of treated hydrocephalus.METHODSThe authors queried the NSBPR to identify all patients with myelomeningoceles. Individuals were identified as having been treated for hydrocephalus if they had undergone at least 1 hydrocephalus-related operation. For each participating NSBPR institution, the authors calculated the proportion of patients with treated hydrocephalus who were enrolled at that site. Logistic regression was performed to analyze the relationship between hydrocephalus and the functional lesion level of the myelomeningocele and to compare the rate of treated hydrocephalus in children born before 2005 with those born in 2005 or later.RESULTSA total of 4448 patients with myelomeningocele were identified from 26 institutions, of whom 3558 patients (79.99%) had undergone at least 1 hydrocephalus-related operation. The rate of treated hydrocephalus ranged from 72% to 96% among institutions enrolling more than 10 patients. This difference in treatment rates between centers was statistically significant (p < 0.001). Insufficient data were available in the NSBPR to analyze reasons for the different rates of hydrocephalus treatment between sites. Multivariate logistic regression demonstrated that more rostral functional lesion levels were associated with higher rates of treated hydrocephalus (p < 0.001) but demonstrated no significant difference in hydrocephalus treatment rates between children born before versus after 2005.CONCLUSIONSThe rate of hydrocephalus treatment in patients with myelomeningocele in the NSBPR is 79.99%, which is consistent with the rates in previously published literature. The authors' data demonstrate a clear association between functional lesion level of the myelomeningocele and the need for hydrocephalus treatment.

Ventriculocisternal Shunt Redivivus: Third Ventricle-Cisterna Magna Intradural Shunt: A Technical Note and Case Report.

OBJECTIVE: To present a hitherto unreported modification of the classic Torkildsen procedure: passing a catheter intracranially, between the third ventricle and cisterna magna. METHODS: We applied our technique to a 56-year-old man who presented to our department for treatment of a pineal region mass. RESULTS: The patient was placed in sitting position and the mass was gross totally removed through a supracerebellar infratentorial approach. After the completion of the tumor resection, the patency of the cerebral aqueduct was checked, but the permeability was doubtful. During the same procedure, a shunt was inserted, under direct microsurgical control, into the third ventricle and passed over the cerebellar surface into the cisterna magna. The postoperative course was uneventful, and the patient was discharged from our unit with no neurological deficits and able to carry on with his day-to-day life. CONCLUSIONS: Our case illustrates that ventriculocisternal shunting can successfully be used in selected cases. The variation we describe can be a valuable surgical strategy in patients with pineal region masses, in whom a supracerebellar infratentorial route is used and in whom uncertainty exists regarding the patency of the sylvian aqueduct.

Hydrocephalus in children under the age of five from diagnosis to short-/medium-/long-term progression: a retrospective review of 142 children.

The aim of this study is to evaluate the clinical history and prognosis of children with early-onset hydrocephalus. The retrospective study's inclusion criteria were hydrocephalus diagnosis before the age of 5 years, independent of aetiology, and birth details, January 1, 2000 to December 31, 2014. Overall, 142 children were entered into the study, divided into 11 aetiological groups: premature-birth post-intraventricular haemorrhage (16%), brain tumours (16%), spina bifida (15%), aqueductal stenosis (8%), post-meningitis (8%), post-haemorrhage (8%), Dandy-Walker malformation (6%), unknown origin (6%), arachnoid cyst (5%), miscellaneous obstruction (4%), and various causes (8%). In total, 23 patients died, primarily from the tumour group. Ventriculostomy, performed 42 times, was successful in 20 patients. Overall, 226 internal shunts were placed in 99 children. Infectious complications affected 19% of children after shunt placement and 51% after mechanical complications. Mean follow-up was 4 years 10 months, with 61% of children progressing fairly well, especially those with aqueductal stenosis, cysts, and unknown or diverse obstructive causes. Post-meningitis hydrocephalus displayed the poorest outcome. Isolated obstructive hydrocephalus exhibited better prognosis, with most obstructive aetiologies effectively treated via ventriculostomy. Children treated by shunt placement were more at risk of complications. Aetiologies with associated abnormalities and neurological sequelae had poorer outcomes.

Clinical management of unruptured intracranial aneurysm in Germany: a nationwide observational study over a 5-year period (2005-2009).

OBJECTIVES: Our aim was to provide nationwide age-standardised rates (ASR) on the usage of endovascular coiling and neurosurgical clipping for unruptured intracranial aneurysm (UIA) treatment in Germany. SETTING: Nationwide observational study using the Diagnosis-Related-Groups (DRG) statistics for the years 2005-2009 (overall 83 million hospitalisations). PARTICIPANTS: From 2005 to 2009, overall 39 155 hospitalisations with a diagnosis of UIA occurred in Germany. PRIMARY OUTCOME MEASURES: Age-specific and age-standardised hospitalisation rates for UIA with the midyear population of Germany in 2007 as the standard. RESULTS: Of the 10 221 hospitalisations with UIA during the observation period, 6098 (59.7%) and 4123 (40.3%) included coiling and clipping, respectively. Overall hospitalisation rates for UIA increased by 39.5% (95% CI 24.7% to 56.0%) and 50.4% (95% CI 39.6% to 62.1%) among men and women, respectively. In 2005, the ASR per 100 000 person years for coiling was 0.7 (95% CI 0.62 to 0.78) for men and 1.7 (95% CI 1.58 to 1.82) for women. In 2009, the ASR was 1.0 (95% CI 0.90 to 1.10) and 2.4 (95% CI 2.24 to 2.56), respectively. Similarly, the ASR for clipping in 2005 amounted to 0.6 (95% CI 0.52 to 0.68) for men and 1.1 (95% CI 1.00 to 1.20) for women. These rates increased in 2009 to 0.8 (95% CI 0.72 to 0.88) and 1.7 (95% CI 1.58 to 1.82), respectively. We observed a marked geographical variation of ASR for coiling and less pronounced for clipping. For the federal state of Saarland, the ASR for coiling was 5.64 (95% CI 4.76 to 6.52) compared with 0.68 (95% CI 0.48 to 0.88; per 100 000 person years) in Saxony-Anhalt, whereas, ASR for clipping were highest in Rhineland-Palatinate (2.48, 95% CI 2.17 to 4.75) and lowest in Saxony-Anhalt (0.52, 95% CI 0.34 to 0.70). CONCLUSIONS: To the best of our knowledge, we presented the first representative, nationwide analysis of the clinical management of UIA in Germany. The ASR increased markedly and showed substantial geographical variation among federal states for all treatment modalities during the observation period.

Stress-Induced Hyperglycemia After Spontaneous Subarachnoid Hemorrhage and Its Role in Predicting Cerebrospinal Fluid Diversion.

BACKGROUND: Stress-induced hyperglycemia (SIH) after acute cerebrovascular disease is common and is associated with adverse clinical outcomes. The incidence of SIH after spontaneous subarachnoid hemorrhage (SAH) and its role in shunt placement have not been systematically investigated. The present study is designed to investigate the incidence of SIH after spontaneous SAH and its determinants. The role of SIH and premorbid hyperglycemia (using glycated hemoglobin [HbA1c]) in predicting external ventricular drainage (EVD) and ventriculoperitoneal shunt (VPS) placement is also investigated. METHODS: This study defined SIH using the glycemic gap (GG) and admission glucose:HbA1c ratio. The receiver operating characteristic curve determined threshold values for GG and the ratio that best predicted incidence of adverse clinical outcomes, including in-hospital mortality. RESULTS: We defined SIH using thresholds of 26.7 mg/dL for GG and 26 mg/dL for admission glucose:HbA1c ratio. The incidence of SIH was higher in patients with aneurysmal SAH (aSAH) (99/200 [49.5%]) than in those with nonaneurysmal SAH (16/50 [32.0%]; P = 0.03). Among 200 patients with aSAH, diabetics had higher mortality than nondiabetics (10/24 [41.7%] vs. 39/137 [21.2%]; P = 0.045). SIH among nonhydrocephalic aSAH was more likely to have EVD placed than those without (42/64 [65.6%] vs. 38/79 [48.1%]; P = 0.043). Among 143 patients with aSAH without hydrocephalus, EVD was placed more often in those with HbA1c level ≥6.4% (15/19 [78.9%] vs. 65/124 [52.4%]; P = 0.045). Neither SIH nor HbA1c level could predict VPS placement among aSAH survivors. CONCLUSIONS: SIH is common after aSAH. In nonhydrocephalic aSAH, both SIH and premorbid uncontrolled hyperglycemia determine EVD but not VPS placement.

Management of External Ventricular Drains After Subarachnoid Hemorrhage: A Multi-Institutional Survey.

BACKGROUND: Patients with aneurysmal subarachnoid hemorrhage (SAH) often develop hydrocephalus requiring an external ventricular drain (EVD). The best available evidence suggests that a rapid EVD wean and intermittent CSF drainage is safe, reduces complications, and shortens ICU and hospital length of stay as compared to a gradual wean and continuous drainage. However, optimal EVD management remains controversial and the baseline practice among neurological ICUs is unclear. Therefore, we sought to determine current institutional practices of EVD management for patients with aneurysmal SAH. METHODS: An e-mail survey was sent to attending intensivists and neurosurgeons from 72 neurocritical care units that are registered with the Neurocritical Care Research Network or have been previously associated with the existing literature on the management of EVDs in critically ill patients. Only one response was counted per institution. RESULTS: There were 45 out of 72 institutional responses (63%). The majority of responding institutions (80%) had a single predominant EVD management approach. Of these, 78% favored a gradual EVD weaning strategy. For unsecured aneurysms, 81% kept the EVD continuously open and 19% used intermittent drainage. For secured aneurysms, 94% kept the EVD continuously open and 6% used intermittent drainage. Among continuously drained patients, the EVD was leveled at 18 (unsecured) and 11 cm H2O (secured) (p < 0.0001). When accounting for whether the EVD strategy was to enhance or minimize CSF drainage, there was a significant difference in the management of unsecured versus secured aneurysms with 42% using an enhance drainage approach in unsecured patients and 92% using an enhance drainage approach in secured patients (p < 0.0001). CONCLUSION: Most institutions utilize a single predominant EVD management approach, with a consensus toward a continuously open EVD to enhance CSF drainage in secured aneurysm patients coupled with a gradual weaning strategy. This finding is surprising given that the best available evidence suggests that the opposite approach is safe and can reduce ICU and hospital length of stay. We recommend a critical reassessment of the approach to the management of EVDs. Given the potential impact on patient outcomes and length of stay, more research needs to be done to reach a threshold for practice change, ideally via multicenter and randomized trials.

Integrating Cerebrospinal Fluid Shunt Quality Checks into the World Health Organization's Safe Surgery Checklist: A Pilot Study.

BACKGROUND: Despite efforts for improvement, cerebrospinal fluid (CSF) shunt failure rates remain high. Recent studies have shown promising reductions in failure rates and infection rates with the routine use of perioperative checklists. This study was conducted to pilot test the feasibility and efficacy of integrating specific CSF shunt surgery quality checks into the World Health Organization (WHO) Surgical Safety Checklist. METHODS: We designed CSF shunt checklist quality items according to a previously established methodology, including solicitation of best practices by a national multidisciplinary expert panel. We examined adherence to key processes before and after implementation as a measure of the efficacy of the integrated checklist. We then surveyed users regarding perceived checklist utility. RESULTS: Overall adherence to shunt-specific key processes increased from 8.6 (95% confidence interval [CI], 7.9-9.2) to 9.9 (95% CI, 9.3-10.4; P = 0.0070) per 12 items, driven by the infection control items (4.7 [95% CI, 4.1-5.3] to 6.0 [95% CI, 5.4-6.4] per 8 items; P = 0.0056). All of the survey respondents indicated that the checklist was easy to use. The majority stated that it helped them feel better prepared to perform the procedure consistently according to evidence-based practice, and that if they were to adhere to the checklist consistently, their rate of shunt failure would be expected to decrease. CONCLUSIONS: The integration of specialty-specific checks into the WHO Safe Surgery Checklist improved adherence to quality processes and generally was well accepted in our pilot study. A larger clinical trial is needed to assess whether this approach could improve shunt outcomes.