Assessment of Ventricular Size and Neurocognitive Outcomes in Children with Postnatal Closure of Myelomeningocele.

OBJECTIVE: To assess if ventricular size before shunting is correlated with neurodevelopmental outcomes in children with postnatal myelomeningocele closure. STUDY DESIGN: This retrospective review included children with postnatal surgical closure of myelomeningocele and neuropsychological testing between 2018 and 2023 at the University of California, San Francisco. Frontal-occipital horn ratio (FOHR) was measured immediately before shunt placement or on the first study that reported ventricular stability for nonshunted patients. The primary outcome was full scale IQ (FSIQ) on the Weschler Intelligence Scale. Secondary outcomes included indices of the Weschler scale, the Global Executive Composite from the Behavior Rating Inventory of Executive Function, and the general adaptive composite from the Adaptive Behavior Assessment Scale. Univariable and multivariable regression was used to determine if FOHR was correlated with neuropsychological scores. RESULTS: Forty patients met the inclusion criteria; 26 (65%) had shunted hydrocephalus. Age at neuropsychological testing was 10.9 ± 0.6 years. FOHR was greater in the shunted group (0.64 vs 0.51; P < .001). There were no differences in neuropsychological results between shunted and nonshunted groups. On univariable analysis, greater FOHR was associated with lower FSIQ (P = .025) and lower Visual Spatial Index scores (P = .013), which remained significant on multivariable analysis after adjusting for gestational age at birth, lesion level, shunt status, and shunt revision status (P = .049 and P = .006, respectively). Separate analyses by shunt status revealed that these effects were driven by the shunted group. CONCLUSIONS: Greater FOHR before shunting was correlated with lower FSIQ and the Visual Spatial Index scores on the Weschler Intelligence Scales. Larger studies are needed to explore further the relationship between ventricle size, hydrocephalus, and neurodevelopmental outcomes.

Permanent Visual Loss as a Complication of Decompressive Surgery for the Treatment of Posterior Fossa Tumours: A Report of Two Cases.

Posterior fossa tumours are one of the most common types of solid neoplasia in paediatric patients. Although impaired vision can occur at presentation, it usually stabilises or improves after decompressive surgery. However, cases of permanent and profound visual loss have been reported following successful tumour resection, despite receiving little attention from the medical community. In this paper, we present two cases of young patients who experienced severe and permanent visual loss following uncomplicated surgery for posterior fossa tumour removal. We discuss the possible mechanism involved in the visual loss and measures to prevent such a dreadful complication.

Bilateral abducens and facial nerve palsies following fourth ventriculoperitoneal shunt with laparoscopic-assisted abdominal catheter placement.

Introduction: Hydrocephalus, altering cerebrospinal fluid (CSF) dynamics, affects 175 per 100,000 adults worldwide. Ventriculoperitoneal shunts (VPS) manage symptomatic hydrocephalus, with 125,000 cases annually. Despite efficacy, VPS face complications, necessitating interventions. Research question: "What are the mechanisms and risk factors for bilateral VIth and VIIth lower motor neuron palsies in hydrocephalus patients with a fourth ventriculoperitoneal shunt?" Material and methods: This study details a 36-year-old female with a neonatal meningitis history, multiple shunt replacements, admitted for abdominal pain secondary to pelvic inflammatory disease. An abdominal shunt catheter removal and external ventricular drain placement occurred after consultation with a general surgeon. A cardiac atrial approach and subsequent laparoscopic abdominal approach were performed without complications. Results: After one month, the patient showed neurological complications, including decreased facial expression, gait instability, and bilateral VIth and VIIth lower motor neuron palsies, specifically upgazed and convergence restriction. Discussion: The complication's pathophysiology is discussed, attributing it to potential brainstem herniation from over-drainage of CSF. Literature suggests flexible endoscopic treatments like aqueductoplasty/transaqueductal approaches into the fourth ventricle. Conclusions: This study underscores the need for increased awareness in monitoring neurological outcomes after the fourth ventriculoperitoneal shunt, particularly in cases with laparoscopic-assisted abdominal catheter placement. The rarity of bilateral abducens and facial nerve palsies emphasizes the importance of ongoing research to understand pathophysiology and develop preventive and therapeutic strategies for this unique complication.

Endoscopic Third Ventriculostomy for the Management of Obstructive Hydrocephalus in Pregnancy: A Case Report and Review of the Literature.

Introduction Hydrocephalus is a condition characterized by the abnormal accumulation of cerebrospinal fluid within the brain's ventricular system. It can stem from obstructive and nonobstructive causes. Pregnancy introduces physiopathological changes that may heighten the risk of developing or worsening symptomatic hydrocephalus. Nevertheless, comprehensive reports on this aspect, especially regarding surgical interventions, remain scarce. Case Report A young woman with a history of recurrent headaches experienced a worsening of her symptoms at the onset of her pregnancy. A magnetic resonance imaging (MRI) in the first trimester revealed increased ventricular dilation, indicating an obstructive cause due to aqueduct stenosis. During a neurosurgical board meeting, treatment options were discussed, considering the identifiable obstruction, the heightened intra-abdominal pressure associated with pregnancy, and the risk of ventricular shunt dysfunction. The patient underwent an endoscopic third ventriculostomy (ETV) without complications, leading to both symptom relief and a successful conclusion to the pregnancy. Discussion Neurosurgical procedures in pregnant women are uncommon due to the increased risks to both the mother and the fetus. However, when performed by a qualified multidisciplinary team, they can lead to positive outcomes. In cases of hydrocephalus during pregnancy, ETV appears to be a viable alternative for surgical intervention, particularly when hydrocephalus becomes symptomatic and an obstructive cause is identified, whether in patients with existing shunts or those with newly developed hydrocephalus.

Management of shunt dysfunction using noninvasive intracranial pressure waveform monitoring: illustrative case.

BACKGROUND: Normal pressure hydrocephalus (NPH) treatment consists of using valves for drainage, as it is for hydrocephalus in general. Despite this, complications can occur, putting the patient at risk, and neurological monitoring is crucial. OBSERVATIONS: A 61-year-old male, who had been diagnosed with NPH 3 years prior and was being treated with a ventriculoperitoneal shunt with a programmable valve, presented to the emergency department because of a traumatic brain injury due to a fall from standing height. No previous complications were reported. He had an altered intracranial pressure (ICP) waveform in the emergency room when monitored with the brain4care device, with a P2/P1 ratio of 1.6. Imaging helped to confirm shunt dysfunction. Revision surgery normalized the ratio to 1.0, and the patient was discharged. Upon return after 14 days, an outpatient analysis revealed a ratio of 0.6, indicating improvement. LESSONS: In selected cases of NPH, noninvasive ICP waveform morphology analysis can be effective as a diagnostic aid, as well as in the pre- and postsurgical follow-up, given the possibility of comparing the values of ICP preoperatively and immediately postoperatively and the outpatient P2/P1 ratio, helping to manage these patients.

Treatment of Idiopathic Normal Pressure Hydrocephalus with a Novel Programmable Valve: Prospective Evaluation of Costs, Efficacy, and Safety.

Objective Programmable valves provide an equal or superior neurological outcome when compared with fixed pressure ones, with fewer complications, in treating idiopathic normal pressure hydrocephalus (iNPH) patients. Long-term costs of these treatments have not been properly compared in literature. We sought to compare costs, efficacy, and safety of 1-year treatment of iNPH patients with programmable valve Sphera Pro and a fixed pressure valve. Materials and Methods A prospective cohort of iNPH patients treated with programmable valve was compared with a historical cohort of iNPH patients treated with fixed pressure valve. Our primary outcome was mean direct cost of treating iNPH up to 1 year. Efficacy in treating iNPH and safety were assessed as secondary outcomes. Statistical Analysis Proportions were compared using chi-square or Fisher's exact tests. Normally distributed variables were compared using the Student's t -test or the Mann-Whitney's U test. Differences in the evolution of the variables over time were assessed using generalized estimating equations. All tests were two-sided, with an α of 0.05. Results A total of 19 patients were analyzed in each group (mean age 75 years, the majority male). Comorbidities and clinical presentation were similar between groups. Both fixed pressure and programmable valve patients had neurological improvement over time ( p < 0.001), but no difference was seen between groups ( p = 0.104). The fixed pressure valve group had more complications than the programmable valve group (52.6% vs. 10.5%, respectively, p = 0.013). Annual treatment cost per patient was US$ 3,820 ± 2,231 in the fixed pressure valve group and US$ 3,108 ± 553 in the programmable valve group. Mean difference was US$712 (95% confidence interval, 393-1,805) in favor of the programmable valve group. Conclusion The Sphera Pro valve with gravitational unit had 1 year treatment cost not higher than that of fixed pressure valve, and resulted in similar efficacy and fewer complications.

Endoscopic Third Ventriculostomy versus Ventriculoperitoneal Shunt in Patients with Obstructive Hydrocephalus: An Updated Systematic Review and Meta-Analysis.

Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) are surgical methods for treating obstructive hydrocephalus. However, there is still disagreement regarding the most effective technique, in terms of both operative success and postoperative complications. Therefore, we performed a systematic review and meta-analysis to compare the efficacy and safety of these two methods in patients with obstructive hydrocephalus. We performed a systematic search of the PubMed, Scopus, and Cochrane Library databases. Randomized clinical trials (RCTs) comparing ETV and VPS in pediatric or adult patients with obstructive hydrocephalus were included. The outcomes included were operative success, postoperative cerebrospinal fluid leak, postoperative infection, postoperative or intraoperative bleeding, blockage rate, and mortality. The risk ratio (RR) was calculated with a 95% confidence interval (CI). Heterogeneity was evaluated with I 2 statistics. We used a fixed-effects model for outcomes with I 2 < 25% and DerSimonian and Laird random-effects model for other conditions. The Cochrane collaboration tool for assessing the risk of bias in randomized trials was used for risk-of-bias assessment. R, version 4.2.1, was used for statistical analyses. Of the 2,353 identified studies, 5 RCTs were included, involving 310 patients with obstructive hydrocephalus, of which 163 underwent ETV. There was a significant difference in favor of ETV for postoperative infection (risk ratio [RR]: 0.11; 95% confidence interval [CI]: 0.04-0.33; p < 0.0001; I 2 = 0%) and blockage rate (RR: 0.15; 95% CI: 0.03-0.75; p = 0.02; I 2 = 53%). Meanwhile, there was no significant difference between groups for the postoperative or intraoperative bleeding (RR: 0.44; 95% CI: 0.17-1.15; p = 0.09; I 2 = 0%), postoperative cerebrospinal fluid leak (RR: 0.65; 95% CI: 0.22-1.92; p = 0.44; I 2 = 18%), operative success (RR: 1.18; 95% CI: 0.77-1.82; p = 0.44; I 2 = 84%), and mortality (RR: 0.19; 95% CI: 0.03-1.09; p = 0.06; I 2 = 0%). Three RCTs had some concerns about the risk of bias and one RCT had a high risk of bias due to the process of randomization and selection of reported results. Thus, this meta-analysis of RCTs evaluating ETV compared with VPS demonstrated that although there is no superiority of ETV in terms of operative success, the incidence of complications was significantly higher in patients who underwent VPS. Our results suggest that the use of ETV provides greater benefits for the treatment of obstructive hydrocephalus. However, more RCTs are needed to corroborate the superiority of ETV.

Factores de riesgo asociados a la persistencia de hidrocefalia posterior a la resección de tumores de fosa posterior / Risk factors associated with hydrocephalus persistence after posterior fossa tumors resection

Introducción. Las neoplasias de fosa posterior son los tumores de sistema nervioso central más frecuentes en la población pediátrica y una causa frecuente de hidrocefalia. El objetivo del presente trabajo es analizar los factores de riesgo asociados a hidrocefalia luego de las cirugías de resección de tumores de fosa posterior en una población pediátrica. Material y métodos. Se realizó un estudio observacional retrospectivo de pacientes pediátricos operados de tumores de fosa posterior en un único hospital. Se analizaron potenciales factores de riesgo pre y post quirúrgicos. Se consideró como variable respuesta la necesidad de derivación definitiva para tratar la hidrocefalia a los 6 meses de la resección tumoral. Resultados. En el análisis univariado se detectaron múltiples factores de riesgo significativos. Sin embargo, solamente 3 se mantuvieron en el modelo multivariado: grado de resección (Subtotal: OR 7.86; Parcial: OR 20.42), infección postoperatoria (OR 17.31) y ausencia de flujo de salida postoperatorio en IV ventrículo (OR 4.29). Éste modelo presentó una buena capacidad predictiva (AUC: 0.80, Sensibilidad 80.5%, Especificidad 76.3%). Conclusión. La realización de tercer ventriculostomía endoscópica preoperatoria no redujo la incidencia de hidrocefalia postoperatoria. El grado de resección tumoral, la presencia de infección postoperatoria y la obstrucción de salida del IV ventrículo fueron los factores de riesgo más importantes para el requerimiento de sistema derivativo definitivo luego de la resección de un tumor de fosa posterior. Ésto podría influir en la toma de decisiones respecto al tratamiento en este grupo de pacientes pediátricos

Background. Posterior fossa tumors are the most frequent central nervous system neoplasms in the pediatric population and a frequent cause of hydrocephalus. The objective of this study is to analyze the risk factors associated with hydrocephalus after posterior fossa tumors resection in a pediatric population. Methods. A retrospective observational study was conducted on pediatric patients who underwent posterior fossa tumor resection in a single hospital. Potential pre- and post-operative risk factors were analyzed. The need for definitive shunt placement to treat hydrocephalus at 6 months after tumor resection was considered as the outcome variable. Results. Univariate analysis identified multiple significant risk factors. However, only 3 factors remained in the multivariate model: extent of resection (subtotal: OR 7.86; partial: OR 20.42), postoperative infection (OR 17.31), and absence of postoperative outflow of the fourth ventricle (OR 4.29). This model showed good predictive capacity (AUC: 0.80, Sensitivity 80.5%, Specificity 76.3%). Conclusion. Preoperative endoscopic third ventriculostomy did not reduce the incidence of postoperative hydrocephalus. The extent of tumor resection, presence of postoperative infection, and obstruction of fourth ventricle outflow were the most important risk factors for the requirement of a definitive shunt system after posterior fossa tumor resection. This could influence treatment decisions in this group of pediatric patients

Intracranial migration of a ventriculoperitoneal shunt: A case report and literature review.

Background: The intracranial migration of a ventriculoperitoneal shunt (VPS) has been previously described, it is a very rare event, and the mechanisms of this migration have not yet been elucidated. Case Description: Newborn at 38 weeks of gestation by cesarean section, with congenital hydrocephalus due to Dandy-Walker malformation that required right Frazier VPS placement. At 2-month follow-up, computed tomography of the skull showed cranial migration of VPS and dysfunction. At evaluation, there were signs of systemic infection. External ventricular drainage was placed and an intravenous antibiotic scheme for Gram-positive bacteria was started. After 3 months, cerebrospinal fluid cultures were negative and definitive VPS was decided. Conclusion: Different possible mechanisms have been proposed, such as negative intraventricular pressure, positive intra-abdominal pressure, use of valveless catheters, excessive burr hole size, as well as such as occipital ventricular access, thin cortical mantle, incorrect distal and proximal fixation, short distance between the peritoneum and ventricles, and a possible inflammatory reaction to the catheter material (silicone). A combination of these different mechanisms contributes to proximal shunt migration. Although the placement of a VPS is a procedure well taught since the 1st years of neurosurgical residency, it is not exempt from complications. Although, as was previously stated in this paper, the incidence of a complete cranial VPS migration is extremely rare, and only a few cases are documented, it is still important to report this type of cases and to try to elucidate the possible mechanisms involved.

Obstructive Hydrocephalus Due to Posterior Fossa Tumors in Adults: A Comparative Analysis of 3 Surgical Techniques.

BACKGROUND: The main treatments for hydrocephalus due to posterior fossa tumors are tumor resection with or without an external ventricular drain, ventriculoperitoneal shunt (VPS), and endoscopic third ventriculostomy. Although preoperative cerebrospinal fluid diversion by any of these techniques improves clinical outcomes, evidence comparing the efficacy of these techniques is scarce. Therefore, we aimed to retrospectively evaluate each treatment modality. METHODS: This single-center study analyzed 55 patients. Treatments were classified as successful (hydrocephalus resolution with a single surgical event) or failed and compared with a χ2 test. Kaplan-Meier curves and log-rank tests were employed. A Cox proportional hazard model was used to determine relevant covariates predicting outcomes. RESULTS: Mean patient age was 36.3 years, 43.4% of patients were men, and 50.9% of patients presented with uncompensated intracranial hypertension. Mean tumor volume was 33.4 cm3, and extent of resection was 90.85%. Tumor resection with or without an external ventricular drain was successful in 58.82% of cases, VPS was successful in 100%, and endoscopic third ventriculostomy was successful in 76.19% (P = 0.014). Mean follow-up time was 15.12 months. Log-rank test found statistically significant differences between survival curves of treatments (P = 0.016) favoring the VPS group. Postoperative surgical site hematoma was a significant covariate in the Cox model (hazard ratio = 17; 95% confidence ratio, 2.301-81.872; P = 0.004). CONCLUSIONS: This study favored VPS as the most reliable treatment of hydrocephalus due to posterior fossa tumors in adult patient; however, several factors influence clinical outcomes. We proposed an algorithm based on our findings and other authors' findings to facilitate the decision-making process.

Noninvasive intracranial pressure monitoring throughout brain compliance guiding a ventriculoperitoneal shunt replacement in hydrocephalus-case report.

INTRODUCTION: Ventriculoperitoneal (VP) shunt is the primary therapy for hydrocephalus in children; however, this technique is amenable to malfunctions, which could be detected through an assessment of clinical signs and imaging results. Furthermore, early detection can prevent patient deterioration and guide clinical and surgical treatment. CASE PRESENTATION: A 5-year-old female with a premedical history of neonatal IVH, secondary hydrocephalus, multiple VP shunts revisions, and slit ventricle syndrome was evaluated using a noninvasive intracranial pressure monitor device at the early stages of the clinical symptoms, evidencing increased intracranial pressure and poor brain compliance. Serial MRI images demonstrated a slight ventricular enlargement, leading to the use of a gravitational VP shunt, promoting progressive improvement. On the follow-up visits, we used the noninvasive ICP monitoring device to guide the shunt adjustments until symptom resolution. Furthermore, the patient has been asymptomatic for the past 3 years without requiring new shunt revisions. DISCUSSION: Slit ventricle syndrome and VP shunt dysfunctions are challenging diagnoses for the neurosurgeon. The noninvasive intracranial monitoring has allowed a closer follow-up assisting early assessment of brain compliance changes related to a patient's symptomatology. Furthermore, this technique has high sensitivity and specificity in detecting alterations in the intracranial pressure, serving as a guide for the adjustments of programmable VP shunts, which may improve the patient's quality of life. CONCLUSION: Noninvasive ICP monitoring may lead to a less invasive assessment of patients with slit ventricle syndrome and could be used as a guide for adjustments of programmable shunts.

Corneal Perforation associated with "Silent Brain Syndrome" / Perfuração corneana associada à "síndrome do cérebro silencioso"

ABSTRACT This case report describes the clinical characteristics and ophthalmic management of a patient who developed corneal perforation due to severe enophthalmos consistent with "silent brain syndrome." A 27-year-old man with a history of congenital hydrocephalus and ventriculoperitoneal shunt was referred with complaints of "sinking of the eyeballs" and progressively decreasing vision in the left eye. Examination revealed severe bilateral enophthalmos in addition to superonasal corneal perforation with iris prolapse in the left eye. The patient underwent therapeutic keratoplasty the next day. Orbital reconstruction with costochondral graft and shunt revision of the intracranial hypotension were performed the next month to prevent further progression.

RESUMO Este relato de caso descreve as características clínicas e o manejo cirúrgico de um paciente que teve perfuração da córnea devido à enoftalmia grave consistente com a "síndrome do cérebro silencioso". Um homem de 27 anos com história de hidrocefalia congênita e derivação ventrículo-peritoneal foi encaminhado com queixas de "afundamento dos globos oculares" e diminuição progressiva da visão no olho esquerdo. O exame revelou enoftalmo bilateral importante, além de perfuração superonasal da córnea com prolapso iriano no olho esquerdo. A paciente foi submetida à ceratoplastia terapêutica no dia seguinte. Foi realizado no mês seguinte a reconstrução da órbita com enxerto costocondral e revisão do shunt para evitar progressão e piora do caso.

The incidence of VP shunt infection in a middle-income nation: a retrospective analysis of a pediatric population.

Objective: To investigate the incidence of infection after ventriculoperitoneal shunt (VPS) insertion at the Bustamante Hospital for Children (BHC), Jamaica, West Indies. Method: Of the 178 patients managed by the Neurosurgery team at BHC, who underwent surgery between 2010 and 2016, 122 patients were subjected to the cerebrospinal fluid (CSF) diversion procedure through a VPS placement. The patients excluded from this study included those with a VPS placed at another institution or one placed prior to the study period. There is a notable transition that saw a switch from the use of the Codman uni-port to Medtronic shunts in 2014-2015, which initiated the process of reuse of shunt passers. Clinical data were retrospectively collected from operating theater logs and available manual health records. Results: Over the 7-year study period of the 122 first-time shunt placements done, 17 patients (13.9%) had positive CSF cultures, with an additional six (4%) having CSF pleocytosis with negative cultures. The most common isolate was the Staphylococcus species, occurring in 60% of VPS infections. The median time to shunt infection was 2 months. Of the 72 Codman shunts placed, six became infected, and 21.7% (10 of 46) of the Medtronic shunts became infected. Conclusion: The rate of incidence of VPS infection was 13.9% for the period between 2010 and 2016, with most infections occurring after 2014. The major causative agent was Staphylococcus species at 60% within a median 2 months of surgery. Overall, this compares well with data reported in the literature.

New Technique Seeking Prophylaxis in the Displacement of Distal Ventriculoperitoneal Shunt Catheter ­ Case Report / Nova técnica buscando profilaxia no desacoplamento do cateter distal de derivação ventriculoperitoneal ­ Relato de caso

Idiopathic intracranial hypertension is a comorbidity treated in neurosurgical practice today with the ventriculoperitoneal derivation technique. However, despite its great safety and efficacy, this technique is susceptible to infrequent failures, such as displacement of the catheter leading to the need for reoperation. In the present article, we report a case involving a peritoneal catheter tip retropulsion for subcutaneous tissue in an obese patient with posterior correction using an extending connector to the distal catheter, without harming the drainage flow. In our case report, the patient went on without complications and without the occurrence of new displacement after 8 months of surgery. The results obtained by this technique supported the idea that this alternative construction minimizes the risk of displacement of the peritoneal tip catheter in obese patients and with high intra-abdominal pressure, helping to reduce the need for reoperations. In addition, the present case report supports the need for further studies and clinical trials on the subject.

A hipertensão intracraniana idiopática é uma comorbidade tratada na prática neurocirúrgica usualmente com técnica de derivação ventriculoperitoneal. No entanto, apesar de sua grande segurança e eficácia, a técnica é sujeita a falhas, pouco frequentes, como o desacoplamento do cateter, levando à necessidade de reoperação. Relatamos, no presente artigo, um caso de correção cirúrgica a partir de prolongamento do cateter distal com a utilização de conector extensor sem prejuízo ao fluxo de drenagem em paciente obeso acometido por recidiva de migração da ponta do cateter peritoneal para o tecido subcutâneo. Em nosso relato de caso, o paciente seguiu sem complicações e sem a ocorrência de novos desacoplamentos após 8 meses do ato operatório. Os resultados obtidos pelo estudo corroboram a necessidade de maiores investigações buscando o conhecimento da eficácia e segurança da técnica empregada buscando minimizar os riscos de migração da ponta do cateter peritoneal em pacientes obesos e de elevada pressão intra-abdominal, ajudando a diminuir a necessidade de reoperações.

Circumbilical Access for Ventriculoperitoneal Bypass Insertion in Adults / Acesso Circumbilical para Inserção de Derivação Ventriculoperitoneal em Adultos

Introduction The use of a minilaparotomy for catheter implantation can bring important complications such as adhesions, intestinal lesions, incisional hernias and postoperative pain. In neurosurgery, the umbilical access, currently widely used by surgeons of different specialties mainly for its aesthetic results, is still restricted by the unfamiliarity of the access. Material and Method During the period between 2019 and 2020, a total of 12 patients who required ventricular bypass were selected, using circumbilical access for insertion of the peritoneal catheter and followed up for 12 months to analyze possible complications. Description of the Technique The surgeon responsible for the abdomen performs an umbilical incision bordering the upper edge of the upper ring, avoiding the mamelon, quickly finding the linea alba under the umbilical plane, which after dissection allows reaching the peritoneum, without breaking the rectus muscles. The peritoneum can then be opened under visual control. Results All patients presented resolution of hydrocephalus with good aesthetic results and without complications. Discussion The aesthetic result of the transumbilical procedure was the stimulus for the development of the technique that proved to be easy, safe, cheap, and aesthetic. Initially, the ease of access to the peritoneal cavity is clear, in addition to avoiding manipulation of the rectus abdominis muscle, which improves postoperative pain. Conclusion The circumbilical access for the implantation of a ventriculoperitoneal shunt is safe, effective and has a better aesthetic result for adult patients and should be part of the operative arsenal of neurosurgeons.

Introdução O uso de uma minilaparotomia para o implante do cateter pode trazer importantes complicações como adesões, lesões intestinais, hérnias incisionais e dor pós-operatória. O acesso umbilical, atualmente muito utilizado por cirurgiões de diversas especialidades principalmente por seus resultados estéticos, na neurocirurgia ainda é restrito pela não familiaridade do acesso. Material e Método Foram selecionados 12 pacientes, durante o período de 2019 e 2020, que necessitavam de derivação ventricular, sendo utilizada o acesso circumbilical para inserção do cateter peritoneal e acompanhada por doze meses para análise de possíveis complicações. Descrição da Técnica O cirurgião responsável pelo abdome realiza uma incisão umbilical margeando a borda superior no rodete superior, fugindo do mamelão, encontrando rapidamente a linha alba sob o plano umbilical que após dissecção permite-se chegar ao peritônio, sem romper os músculos retos. O peritônio pode então ser aberto sob controle visual. Resultados Todos os pacientes apresentaram resolução da hidrocefalia com bom resultado estético e sem complicações. Discussão O resultado estético do procedimento transumbilical foi o estímulo para o desenvolvimento da técnica que se mostrou fácil, segura, barata e estética. Inicialmente é nítido a facilidade do acesso à cavidade peritoneal, além de evitar a manipulação do musculo reto abdominal, o que melhora a dor pós-operatória. Conclusão O acesso circumbilical para a implantação de derivação ventriculoperitoneal é seguro, efetivo e possui melhor resultado estético para pacientes adultos, devendo fazer parte do arsenal operatório de neurocirurgiões.

Ten Steps for NPH Management: Advancements in Diagnosis and Treatment of Adult Hydrocephalus / Dez etapas para o manejo da NPH: avanços no diagnóstico e tratamento da hidrocefalia em adultos

Objectives The authors of the present study intend to describe a straightforward protocol for normal pressure hydrocephalus diagnosis and management, with the employment of a multidisciplinary team approach effort. Methods Using a strict methodological approach for initial diagnosis, taking into consideration occupational therapy and physical therapy assessment, the authors have set out to elaborate a simple protocol for suspicion and, once diagnosed, treatment of normal pressure hydrocephalus. We have used the MoCA (Montreal Cognitive Assessment) and walking assessment that included speed, independence, and distance (SID), 10 m walk test, TUG (timed up and go) evaluation, 6-minute Walk Test, MiniBESTest, as the main factors for pre and post lumbar drainage assessment, after which, the alternatives were deliberated and followed, or not, by ventriculoperitoneal shunt insertion. Results The authors have described a protocol, consisting of ten easy steps, which involves a multidisciplinary team, including occupational therapy and physical therapy professionals, as well as neurologists and neurosurgeons for improved and objective assessment prior to insertion of lumbar drain and, thereafter, detecting the population at most benefit for ventriculoperitoneal shunt insertion. We have described the Ten Step Approach for Normal Pressure Hydrocephalus management, including from initial clinical presentation and imaging, to pre and post lumbar drainage, for lastly deciding upon necessity for ventriculoperitoneal shunt insertion. Conclusions A straightforward protocol for normal pressure hydrocephalus seems not only feasible, but simple to implement in most neurosurgical departments, with good accuracy of prediction of lumbar drainage assessment to shunting outcomes.

Intraparenchymal pericatheter cyst as an indicator of ventriculoperitoneal shunt malfunction: A case-based update.

Background: Intraparenchymal pericatheter cysts (IPCs) are a rare ventriculoperitoneal shunt (VPS) complication, with only a few cases recorded in the literature. Case Description: We report a 22-year-old woman admitted with headache, papilledema, vision loss, and a history of leukemia. Lumbar puncture revealed idiopathic intracranial hypertension (IIH). Three months after VPS implantation, she was readmitted with headache and worsening of visual impairment. CT evidenced a IPC with perilesional edema. Intraoperatively, a shunt revision and cyst drainage were opted for. We present a discussion and literature review on this unique complication of VPS, with emphasis on management. Conclusion: It is important to understand and consider IPCs as complications of VPS surgery, including in adult patients and IIH cases.

Peritoneal metastasis of a brainstem anaplastic ganglioglioma in a 2-year-old boy: case report and literature review.

Anaplastic gangliogliomas (AGG) are rare tumors of the central nervous system (CNS) that commonly affect children and young adults, with an unusual infratentorial presentation, which is related to hydrocephalus and a worse prognosis. We report a case of a brainstem AGG in a 2-year-old boy who underwent a ventriculoperitoneal shunting (VPS) and later presented peritoneal metastasis. We also reviewed the related literature. Even though rare, disease dissemination through VPS should be sought in patients with CNS tumors and VPS who develop new abdominal symptoms. The early diagnosis and intervention may minimize morbidity and improve quality of life of such patients.

Rare case of migration and perforation of the urinary bladder by ventriculoperitoneal shunt catheter with intravesical knotted formation: A case report and literature review.

Background: The most commonly used technique in the management of hydrocephalus is a neurosurgical procedure, known as ventriculoperitoneal shunt (VPS). Several complications of the distal end of a VPS catheter have been described in the literature, although migration and erosive bladder perforation of this shunt are extremely uncommon. Case Description: We relate a rare pediatric case of a 4-year-old boy, with long-term dysuria, intermittent incontinence, and chronic abdominal pain developed during a myelomeningocele postoperative period, without other symptoms. A bladder fistula with the distal end of the VPS inside the bladder was observed while performing an ultrasound to investigate the urinary tract. Two months before the current surgical approach, the patient, with hydrocephalus and alterations compatible with Chiari malformation, was treated with VPS and subsequently subjected to the third ventriculostomy. The child was unsuccessfully treated with an infraumbilical laparotomy, with section and careful traction of the catheter. A vesicostomy was then performed and the catheter was observed to form an intravesical knot. Conclusion: The intravesical knot formation is extremely rare and its mechanism of formation is still not well understood. Patients with VPS need adequate medical follow-up to identify possible complications of the shunt.

Intracranial thrombosis after ventriculoperitoneal shunting.

We report a case of intracranial thrombosis (IT) after ventriculoperitoneal shunting (VPS). We reviewed the literature to highlight the importance of considering the possibility of cerebral venous thrombosis following VPS, even though it is a rarely reported complication. A 14-year-old boy underwent distal catheter replacement due to its short size that was detected during a routine consultation. Five days postoperatively, he experienced nausea, vomiting, seizures, and headache. Although a diagnosis of meningitis was considered, diagnosis of IT was eventually confirmed through computed tomography venography and gadolinium magnetic angioresonance. The patient subsequently underwent anticoagulant therapy, which led to complete resolution of symptoms. In this report, we suggest a possible association between VPS and IT, which is a complication that is not commonly reported. The literature suggests that decreased blood flow due to over-drainage of CSF after VPS causes decreased head pressure, culminating in venous stasis and consequent thrombosis. In addition, the literature describes associations between IT and lumbar puncture (LP); therefore, it is important to consider the possibility of IT following these procedures.