"Artificial intelligence-driven infection risk prediction in ventriculoperitoneal shunting: a novel approach for normal pressure hydrocephalus treatment".

Idiopathic normal pressure hydrocephalus (iNPH) affects approximately 1.5% of the population, with a higher prevalence in men than women. Ventriculoperitoneal shunting (VPS) is the standard treatment for iNPH, but it poses a notable risk of infection, occurring in 8-10% of cases. Recent advancements in non-invasive diagnostic techniques, such as superb microvascular ultrasound (SMI), have demonstrated potential in evaluating cerebrospinal fluid (CSF) flow within VPS systems. A single-center feasibility study involving 19 asymptomatic patients with VPS systems showed that SMI reliably detected CSF flow in the proximal catheter in all patients and in the distal catheter in 89.5%, while reductions in optic nerve sheath diameter (ONSD) indicated lowered intracranial pressure after shunt activation. These findings suggest that SMI could serve as a safer alternative to invasive methods for assessing shunt function. Additionally, artificial intelligence (AI)-based approaches are being explored to reduce infection risk and enhance shunt efficacy. An artificial neural network (ANN) model achieved an 83.1% accuracy in predicting infection risk, surpassing traditional logistic regression models. However, the study's limitations, including its retrospective design, small sample size, and single-center nature, underscore the need for larger multi-center studies to confirm the generalizability of these findings. Further research is essential to validate the effectiveness of these innovations and their potential to improve patient outcomes in hydrocephalus management.

Treatment of post-thalamic hemorrhage hydrocephalus: ventriculoperitoneal shunt or endoscopic third ventriculostomy? A retrospective observational study.

BACKGROUND: The aim of this study was to compare the efficacy of ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV) for the treatment of hydrocephalus after thalamic hemorrhage (TH) where external ventricular drainage (EVD) could not be removed after hematoma absorption, and to provide a theoretical basis for the clinical treatment of hydrocephalus after TH. METHODS: The clinical data of patients with hydrocephalus after TH whose EVD could not be removed after hematoma absorption were retrospectively analyzed. According to the patients' surgical methods, the patients were divided into the VPS group and ETV group. The operative time, length of hospital stay, complications, and reoperation rates of the two groups were compared. RESULTS: There was no statistically significant difference in intraoperative bleeding, length of hospital stay between the two groups. The EVD tubes were successfully removed in all patients after surgery. There were 4 (9.5%) complications in the ETV group and 3 (6.7%) complications in the VPS group, with no statistically significant difference in postoperative complications between the two groups. During the 1-year follow-up, 7 patients (16.7%) in the ETV group and 3 patients (6.7%) in the VPS group required reoperation. In the subgroup analysis of TH combined with fourth ventricular hemorrhage, 6 patients (14.3%) in the ETV group and 1 patient (2.2%) in the VPS group required reoperation, and the difference between the two groups was statistically significant. CONCLUSIONS: ETV had good efficacy in treating hydrocephalus caused by TH and TH that broke into the lateral ventricle and the third ventricle. However, if hydrocephalus was caused by TH with the fourth ventricular hematoma, VPS was a better surgical method because the recurrence rate of hydrocephalus in ETV was higher than that in VPS. Therefore, the choice of surgical method should be based on the patient's clinical features and hematoma location.

A Rare Complication of Proteus Brain Abscess Due to Coccidioidomycosis Causing Hydrocephalus.

Proteus mirabilis is a very common gram-negative facultative anaerobe seen in urinary tract infections. This rod-shaped bacterium tends to cause urolithiasis via its ability to alkalinize the urine. However, in some cases, this bacterium has been shown to cause bacteremia as well as other complicated infections. Here we would like to present a rare case of Proteus mirabilis that has invaded the brain in a patient that has a ventriculoperitoneal (VP) shunt placed due to coccidioidal meningitis causing hydrocephalus. We would also like to discuss the importance of the monitoring of VP shunt and discuss their likelihood of infections and the medical as well as surgical management.

Re-examining the classification of abdominal pseudocysts as surgical site infections through review of broad-range polymerase chain reaction results.

BACKGROUND: The Hydrocephalus Clinical Research Network-quality group (HCRNq) historically defined all abdominal pseudocysts associated with a ventriculoperitoneal shunt as a surgical site infection regardless of culture result. METHODS: We retrospectively reviewed broad-range polymerase chain reaction (BRPCR) results sent between January 2017 and July 2023 from abdominal pseudocyst fluid sent from hospitals around the country to a reference laboratory to help further characterize these collections. RESULTS: A total of 19 samples were tested via BRPCR between 1/2017 and 7/2023. Two (10.5 %) had organisms identified; one with Staphylococcus epidermidis and one with Candida parapsilosis. No fastidious organisms that would be expected to not grow with typical culture techniques were identified. CONCLUSIONS: Few abdominal pseudocysts had organisms identified by BRPCR, suggesting that not all pseudocysts are due to infectious causes. Consideration should be given to alternate causes of pseudocyst development when cultures are negative.

Ventriculoatrial shunt remains a safe surgical alternative for hydrocephalus: a systematic review and meta-analysis.

Hydrocephalus is a commonly encountered pathology in the neurosurgical practice. Since the first permanent ventriculo-subarachnoid-subgaleal shunt described by Mikulicz in 1893, there were multiple attempts to find solutions for draining the excess production/less reabsorption of the cerebrospinal fluid (CSF) from the brain. Nowadays, the most common technique is the ventriculoperitoneal shunt (VPS), whereas the ventriculoatrial shunt (VAS) is applied only in some rare conditions. To date there are still no specific guidelines or strong evidence in literature that guide the surgeon in the choice between the two methods, and the decision usually relies on the confidence and expertise of the surgeon. Considering the lack of established recommendations, this systematic review and meta-analysis aims to evaluate the effectiveness and safety of these two shunting techniques. This systematic review was conducted following the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). No chronological limits of study publications were included. Prospective and retrospective clinical studies, and reports of case series with at least five patients per group and reporting data on comparison between VAS and VPS techniques were eligible for inclusion. Nine studies reporting 3197 patients meeting the inclusion and exclusion criteria were identified and included in the quantitative synthesis. The risk of shunt dysfunction/obstruction was significantly lower in the VAS group [odds ratio (OR) 0.49, 95%-CI 0.34-0.70, I2 0%]. The risk of infection was not significantly different between the two groups (OR 1.02, 95%-CI 0.59-1.74, I2 0%). The risk of revision was not significantly different between the two groups; however, the heterogeneity between the studies was significant (OR 0.73, 95%-CI 0.36-1.49, I2 91%). Additionally, the risk of death was not significantly different between the two groups; however, the heterogeneity between the studies was high (OR 1.93, 95%-CI 0.81-4.62, I2 64%). VAS remains a safe surgical alternative for hydrocephalus. The results of this study highlight a lower risk of shunt dysfunction/obstruction variable in the VAS group, with no significant statistical differences regarding the occurrence of at least one infection-related complication. In consequence, the choice between these two techniques must be tailored to the specific characteristics of the patient.Protocol Registration: The review protocol was registered and published in Prospective Register of Systematic Reviews (PROSPERO) ( www.crd.york.ac.uk/PROSPERO ) website with registration number: CRD42023479365.

Comparing motor development in children with hydrocephalus after treatment with ventriculoperitoneal shunt and endoscopic third ventriculostomy: a cross-sectional study.

Introduction: Ventriculoperitoneal shunt insertion (VPSI) and endoscopic third ventriculostomy (ETV) are the major procedures for treating pediatric hydrocephalus. However, studies comparing motor development following the two treatments are limited. Objective: We aimed to determine motor development outcomes in children with hydrocephalus up to 2 years of age after undergoing VPSI or ETV, to identify which surgical approach yields better motor outcomes and may be more effective for Malawian children. Methods: This was a cross-sectional study where we recruited two groups of participants: one group consisted of children with hydrocephalus treated with VP shunt whilst the other group were treated with ETV, at least 6 months prior to this study. Participants were identified from the hospital records and were called to come for neurodevelopmental assessment using the Malawi Development Assessment Tool (MDAT). Results: A total 152 children treated for hydrocephalus within an 18-month period met the inclusion criteria. Upon follow up and tracing, we recruited 25 children who had been treated: 12 had VPSI and 13 had ETV. MDAT revealed delays in both assessed motor domains: 19 out of the 25 children had delayed gross motor whilst 16 of 25 had delayed fine motor development. There was no significant difference between the shunted and the ETV groups. Conclusion: Children with hydrocephalus demonstrate delays in motor development six to 18 months after treatment with either VPSI or ETV. This may necessitate early and prolonged intensive rehabilitation to restore motor function after surgery. Long-term follow-up studies with bigger sample sizes are required to detect the effect of the two treatment approaches.

Peripheral white blood cell patterns in children with hydrocephalus as a response to ventriculo-peritoneal shunt infection.

Shunt infection is one of the most common complications of conventional hydrocephalus treatment. The route of invasion of a pathogen can modify the immune response of the CNS. The aim of the study is to analyze the immune response to shunt infection caused by S. epidermidis in children with hydrocephalus. The immune response to the pathogen will be analyzed on the basis of, inter alia, simple laboratory test results, such as changes in the pattern of white blood cells, including neutrophils, monocytes, and lymphocytes. The entire study analyzes changes in general parameters of the cerebrospinal fluid (pleocytosis, protein level, glucose level) and in levels of selected interleukins (IL-6, CXCL8 / IL-8, CCL3 / MIP-1a) in the cerebrospinal fluid. The clinical material analyzed in the study was collected in 2010-2014. The study group consisted of 30 patients, who were admitted to the hospital due to their first-ever episode of valve dysfunction caused by S. epidermidis infection. The control group consisted of 30 children who also suffered from congenital hydrocephalus but had not been operated on before. The most pronounced response to CSF infection in the study group was a significant increase in the counts of all investigated WBC lines in the samples collected immediately after the patients' admission to the ward. The earliest aberration of the CSF was a significant increase in protein level. An infection of a ventriculoperitoneal shunt caused by S. epidermidis evokes a very early peripheral blood response. In children affected by a ventriculoperitoneal valve infection, the humoral immune response detected in the cerebrospinal fluid precedes the increase in the level of pleocytosis. The highest level of cytokines in the cerebrospinal fluid is achieved when the pathogens are cleared. Phagocytes, and, in particular, monocytes, play an important role in the normalization of the cerebrospinal fluid parameters after the elimination of S. epidermidis. The local immune response of the central nervous system plays an important role in extinguishment of the inflammatory process.

Prompt closure versus gradual weaning of external ventricular drain for hydrocephalus following aneurysmal subarachnoid haemorrhage: a statistical analysis plan for the DRAIN randomised clinical trial.

BACKGROUND: Insertion of an external ventricular drain (EVD) is a first-line treatment of acute hydrocephalus caused by aneurysmal subarachnoid haemorrhage (aSAH). Once the patient is clinically stable, the EVD is either removed or replaced by a permanent internal shunt. The optimal strategy for cessation of the EVD is unknown. Prompt closure carries a risk of acute hydrocephalus or redundant shunt implantations, whereas gradual weaning may increase the risk of EVD-related infections. METHODS: DRAIN (Danish RAndomised Trial of External Ventricular Drainage Cessation IN Aneurysmal Subarachnoid Haemorrhage) is an international multicentre randomised clinical trial comparing prompt closure versus gradual weaning of the EVD after aSAH. The primary outcome is a composite of VP-shunt implantation, all-cause mortality, or EVD-related infection. Secondary outcomes are serious adverse events excluding mortality and health-related quality of life (EQ-5D-5L). Exploratory outcomes are modified Rankin Scale, Fatigue Severity Scale, Glasgow Outcome Scale Extended, and length of stay in the neurointensive care unit and hospital. Outcome assessment will be performed 6 months after ictus. Based on the sample size calculation (event proportion 80% in the gradual weaning group, relative risk reduction 20%, alpha 5%, power 80%), 122 participants are required in each intervention group. Outcome assessment for the primary outcome, statistical analyses, and conclusion drawing will be blinded. Two independent statistical analyses and reports will be tracked using a version control system, and both will be published. Based on the final statistical report, the blinded steering group will formulate two abstracts. CONCLUSION: We present a pre-defined statistical analysis plan for the randomised DRAIN trial, which limits bias, p-hacking, and data-driven interpretations. This statistical analysis plan is accompanied by tables with simulated data, which increases transparency and reproducibility. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03948256. Registered on May 13, 2019.

Impact of dual procedures: How combining VP shunt placement for hydrocephalus and myelomeningocele repair in newborns affects complication rates?

To discern the efficacy of simultaneous versus delayed VPS surgery in managing hydrocephalus linked with MMC repair: The debate over the concurrent or deferred placement of ventriculoperitoneal shunts (VPS) during myelomeningocele (MMC) repair in hydrocephalic neonates necessitates a nuanced evaluation of associated risks and benefits. While VPS placement can mitigate cerebrospinal fluid (CSF) leaks and minimize wound dehiscence post-MMC repair, it concurrently introduces potential hazards such as infections and shunt-related malfunctions. This prospective cohort study focused on144 newborns with spinal myelomeningocele and hydrocephalus. Divided into two groups based on the timing of dysraphism repair and VPS placement, 101 children underwent concurrent procedures, while 43 received deferred VPS insertion post-MMC closure. Female patients constituted 60% of the cohort, with lumbar lesions being predominant. The median age for MMC closure was three days. Analysis revealed that the deferred insertion group exhibited higher rates of shunt malfunctions, CSF leaks, and wound dehiscence compared to the concurrent insertion group. Although indications hinted at a potential increase in shunt infections in the immediate insertion group, statistical significance was lacking. The study established a statistically significant association between the timing of shunt insertion during MMC repair and specific outcomes, such as CSF leaks and wound dehiscence. The findings suggest that concurrent shunt insertion during MMC repair may reduce the incidence of these complications compared to deferred insertion. However, no substantial differences emerged in terms of shunt infection and malfunction, emphasizing the persistent challenges associated with these major complications.

Ventriculoperitoneal shunt patients and glaucoma: a cohort analysis of the NPH registry.

BACKGROUND: Idiopathic Normal Pressure Hydrocephalus (iNPH) is a chronic condition affecting the elderly. It is characterized by a triad of symptoms and radiological findings. Glaucoma is the leading cause of irreversible blindness worldwide. Earlier studies have proposed that the rate of glaucoma is higher in iNPH patients, and of a possible link between ventriculoperitoneal shunt (VP) treatment and the development of glaucoma. OBJECTIVES: This study aimed to determine the prevalence of glaucoma among iNPH patients and assess the impact of VPs on glaucoma prevalence. METHODS: A cohort study was conducted at Kuopio University Hospital (KUH), including 262 patients with a ventriculoperitoneal shunt. Clinical data were obtained from the Kuopio NPH Registry and medical records. Patients were grouped by iNPH status: iNPH (+) - probable/possible iNPH (n = 192), and iNPH (-) - other causes of hydrocephalus (congenital, secondary, obstructive) (n = 70). We conducted statistical analysis using the Independent Samples T-test, Fisher's exact test, and Pearson Chi-Square. We compared demographics, glaucoma prevalence, brain biopsies positive for Amyloid-ß (Aß) and hyperphosphorylated tau (HPτ) as well as comorbidities for hypertension and diabetes medication. Age stratification assessed glaucoma prevalence in the full cohort. RESULTS: Both iNPH (+) and iNPH (-) groups had comparable demographic and comorbidity profiles. The prevalence of glaucoma in the iNPH (+) group was 11.5% (n = 22) and 11.4% (n = 8) in the iNPH (-) group without a statistically significant difference (p = 1.000). Brain biopsies positive for Amyloid-ß (Aß) and hyperphosphorylated tau (HPτ) were similar. CONCLUSIONS: Neither shunted iNPH patients nor those with a comorbid condition other than iNPH showed a markedly higher prevalence of glaucoma. Instead, both groups exhibited age-related increases in glaucoma prevalence, similar to the trends observed in population-based studies. Our data does not suggest a correlation between VP shunts and an elevated rate of glaucoma.

Scrotal migration of a ventriculoperitoneal shunt.

Ventriculoperitoneal shunt (VPS) is the most common procedure done for hydrocephalus in the paediatric population. While shunt infection and shunt malfunction remain the most common complications, shunt migration is not frequently observed. Being present in a large peritoneal cavity, theoretically, a shunt can travel to a variety of locations. Even among these, scrotal migration is quite uncommon. This case highlights the significance of keeping this possibility in mind while evaluating a case of shunt malfunction. It also discusses various nuances of surgically managing scrotal migration.

Modified ventriculoperitoneal shunt applied to temporary external ventricular drainage.

External ventricular drainage (EVD) is a common procedure in neurosurgical practice. Presently, the three methods used most often include direct EVD (dEVD), long-tunneled external ventricular drains (LTEVDs), and EVD via the Ommaya reservoir (EVDvOR). But they possess drawbacks such as limited duration of retention, vulnerability to iatrogenic secondary infections, and challenges in regulating drainage flow. This study aimed to explore the use of a modified ventriculoperitoneal shunt (mVPS)-the abdominal end of the VPS device was placed externally-as a means of temporary EVD to address the aforementioned limitations. This retrospective cohort study, included 120 cases requiring EVD. dEVD was performed for 31 cases, EVDvOR for 54 cases (including 8 cases with previously performed dEVD), and mVPS for 35 cases (including 6 cases with previously performed EVDvOR). The one-time success rate (no need for further other EVD intervention) for dEVD, EVDvOR, and mVPS were 70.97%, 88.89%, and 91.42%, dEVD vs EVDvOR (P < 0.05), dEVD vs mVPS (P < 0.05), EVDvOR vs mVPS (P > 0.05). Puncture needle displacement or detachment was observed in nearly all cases of EVDvOR, while no such complications have been observed with mVPS. Apart from this complication, the incidence of postoperative complications was 35.48%, 14.81%, and 8.5%, dEVD vs EVDvOR (P < 0.05), dEVD vs mVPS (P < 0.05), EVDvOR vs mVPS (P > 0.05). Mean postoperative retention for EVD was 14.68 ± 9.50 days, 25.96 ± 15.14 days, and 82.43 ± 64.45 days, respectively (P < 0.001). In conclusion, mVPS significantly extends the duration of EVD, which is particularly beneficial for patients requiring long-term EVD.

Diffuse peritoneal dissemination of intracranial pure germinoma via ventriculoperitoneal shunt.

Germinomas frequently cause hydrocephalus, and ventriculoperitoneal shunts (VPS) have been commonly used for their management. Although VPS can potentially serve as a route for peritoneal dissemination of germinomas, the abdominal imaging characteristics of this rare yet important complication remain unknown. In this article, we report the computed tomography imaging findings of diffuse peritoneal dissemination of intracranial germinoma.

Cerebrospinal Fluid Parameters Predicting Contralateral Isolated Lateral Ventricle in Adult Tuberculous Meningitis with Hydrocephalus Post-Ventriculoperitoneal Shunt.

OBJECTIVE: Hydrocephalus, a major complication in tuberculous meningitis (TBM) patients, often necessitates treatment via ventriculoperitoneal shunt (VPS). However, post-VPS, some patients develop a complication called contralateral isolated lateral ventricle (CILV), leading to persistent hydrocephalus symptoms. This study aims to evaluate cerebrospinal fluid (CSF) parameters in predicting CILV occurrence post-VPS in adult TBM patients. METHODS: A retrospective analysis was conducted, focusing on the relationship between preoperative CSF parameters and the development of CILV in 40 adult TBM patients who underwent VPS. The study compared CSF parameters from lumbar puncture after admission with those from ventricular CSF post-external ventricular drainage tube insertion. RESULTS: CILV was observed in 6 of the 40 patients following VPS. Statistical analysis showed no significant difference between the CSF parameters obtained via lumbar and ventricular punctures. Notably, the mean CSF glucose level in patients with CILV was significantly lower (1.92 mmol/L) compared to the non-CILV group (3.03 mmol/L). Conversely, the median adenosine deaminase (ADA) level in the CILV group was higher (5.69 U/L) compared to the non-CILV group (3.18 U/L). The optimal cutoff values for CSF glucose and ADA levels were 1.90 mmol/L and 4.80 U/L, respectively, with a sensitivity of 66.67% and 83.33% and a specificity of 88.24% and 79.41%. CONCLUSIONS: The study identified elevated ADA levels and decreased glucose levels in CSF as potential risk factors for CILV development in adult TBM patients post-VPS. These findings suggest the necessity for more tailored surgical approaches, in patients with altered CSF parameters to mitigate the risk of CILV.

Ventriculoperitoneal shunt infection and malfunction in adult patients: incidence, risk factors, and long-term follow-up of single institution experience.

Ventriculoperitoneal shunt surgery was developed to manage excessive cerebrospinal fluid (CSF) in the brain's ventricles and is considered a mainstream treatment. Despite the development of the shunt device system, various complications still occur. In this study, we reported 307 cases and a long-term follow-up of at least five years of adult patients who underwent VP shunt surgery and analyzed various factors that may affect revision surgery. A retrospective study was conducted at Asan Medical Center, Korea, a tertiary medical center. We reviewed 307 cases from January 2012 to December 2018. The patients' neurological status, predisposing medical conditions, laboratory findings, and other operation-related factors were reviewed using electrical medical records. The normal function group comprised 272 cases (88.6%), and the overall incidence of revision group comprised 35 cases (11.4%). Of the 35 revision surgery cases, 30 (85.71%) were due to shunt malfunctions, such as obstruction, overdrainage, and valve-related errors while 5 (14.29%) were due to shunt infection. Patient demographics, mental status, and operation time did not influence revision as risk factors. Serum laboratory findings showed no statistical difference between the two groups. The white blood cell (WBC) count in the CSF profile differed significantly between the two groups. The Hakim Programmable valve (Codman, USA) is mainly used in our center. In addition, various shunt systems were used, including Strata Regulatory valve (Medtronic, USA), proGAV (Aesculap, USA), and Accu-Flo (Codman, USA). This study analyzed the factors affecting long-term outcomes. Based on these findings, efforts are needed to achieve more favorable outcomes in the future.

Tension Subdural Hygroma Following Resection of Posterior Fossa Tumour in a Child: A new clinico-radio-pathological entity.

Persistent hydrocephalus is common in children after resection of posterior fossa tumours. However, occurrence of subdural hygroma is very rare. We report the case of a 14-month-old child who presented at a paediatric neurology clinic in Muscat, Oman in 2021 who developed a tense subdural hygroma with stable hydrocephalus, in the early postoperative period, following posterior fossa tumour resection. We describe the distinctive clinical, radiological and pathological features associated with the development of a tense subdural hygroma. We also discuss the management by cerebrospinal fluid diversion, which includes either a ventriculoperitoneal or subduroperitoneal shunt. This unique condition is distinguished from external hydrocephalus by features that are critical to the management strategy.