Ventriculo-gallbladder shunt: case series and literature review.

BACKGROUND: The ventriculoperitoneal shunt (VPS) is the gold-standard surgical technique to treat hypertensive hydrocephalus; however, it may fail in 20 to 70% of cases. The present study shows an alternative for patients with contraindications to VPS. METHODS: A case series of nine patients. The medical records of all patients under 17 years of age who underwent ventriculo-gallbladder (VGB) shunt at a pediatric hospital from January 2014 to October 2022 were reviewed. RESULTS: There were 6 (66.7%) males and 3 (33.3%) females. The average age of 73.6 months or 6.1 years at the time of surgery. They had undergone, on average, 5.1 VPS reviews before the VGB shunt. Five (55.5%) had complications of VGB shunt: infection (11.1%), atony (11.1%), hypodrainage (11.1%), and ventriculoenteric fistula (22.2%); all these patients got better at surgical reapproach, and in two of them, the VGB shunt was re-implanted. CONCLUSION: This case series shows a lower risk of death and a similar risk of complications compared to other alternative shunts. This article spotlighted VGB as a viable alternative when VPS fails or has contraindications.

Trapped Fourth Ventricle: Pathophysiology, History and Treatment Strategies.

Trapped fourth ventricle is a clinic-radiological entity characterised by progressive neurological symptoms due to enlargement and dilatation of fourth ventricle secondary to obstruction to its outflow. There are several causative mechanisms for the development of trapped fourth ventricle, including previous haemorrhage, infection or inflammatory processes. However, this condition is most commonly observed in ex preterm paediatric patients shunted for a post-haemorrhagic or post-infective hydrocephalus. Until the introduction of endoscopic aqueductoplasty and stent placement, treatment of trapped fourth ventricle was associated with high rates of reoperation and complications resulting in morbidity. With the advent of new endoscopic techniques, supratentorial and infratentorial approaches for aqueductoplasty and stent insertion have revolutionised the treatment of trapped fourth ventricle. Fourth ventricular fenestration and direct shunting remain viable options in cases where aqueduct anatomy and length of obstruction is not surgically favourable for endoscopic approaches. In this book chapter, we explore the background, historical developments,$ and surgical treatment strategies in the management of this challenging condition.

Cerebrospinal fluid shunt malfunctions: A reflective review.

PURPOSE: Pediatric hydrocephalus is a common and challenging condition. To date, the ventriculoperitoneal shunt (VPS) is still the main lifesaving treatment option. Nonetheless, it remains imperfect and is associated with multiple short- and long-term complications. This paper is a reflective review of the current state of the VPS, our knowledge gaps, and the future state of shunts in neurosurgical practice. METHODS AND RESULTS: The authors' reflections are based on a review of shunts and shunt-related literature. CONCLUSION: Overall, there is still an urgent need for the neurosurgical community to actively improve current strategies for shunt failures and shunt-related morbidity. The authors emphasize the role of collaborative efforts amongst like-minded clinicians to establish pragmatic approaches to avoid shunt complications.

Enterococcus gallinarum group meningitis after transanal migration of the ventriculoperitoneal shunt: a pediatric case report.

In the literature, only 11 Enterococcus gallinarum group meningitis has been reported so far. The Enterococcus gallinarum group was shown for the first time in a pediatric patient presenting with meningitis after bowel perforation, a complication of a ventriculoperitoneal shunt. A 30-month-old male patient presented with vomiting and fever, with the ventriculoperitoneal shunt distal catheter protruding from the anal orifice. The patient was diagnosed with intestinal perforation and meningitis. Enterococcus gallinarum group bacterial yield in cerebrospinal fluid culture. A total of 6 weeks of intravenous antibiotic treatment was given in the hospital. After the treatment, the patient was re-ventriculoperitoneal shunt and was discharged. Among the shunt complications, meningitis with intestinal perforation is rare. It should be kept in mind that meningitis in such patients may be caused by very rare microbiological factors such as Enterococcus gallinarum group. Antibiotherapy should be given according to the culture result. Then planning should be made for a permanent shunt.

A ventricular catheter that migrated into the fourth ventricle successfully removed using a neuroendoscope.

BACKGROUND: In order to remove a foreign body in the ventricle, such as a ventricular drainage catheter, craniotomy and corticotomy are required to access the ventricle. A case in which a catheter in the 4th ventricle was safely removed with a flexible neuroendoscope is reported. CASE DESCRIPTION: A 47-year-old man underwent coil embolization and ventricular drainage for subarachnoid hemorrhage. 10 days after the operation, he tore off the ventricular drainage catheter and the catheter remained intracranially. The tip of the catheter was in the 4th ventricle and the operation to remove remaining catheter with a neuroendoscope was performed. Using a neuroendoscope, we could remove the catheter safely and did not detect the complications. CONCLUSION: To date, there have been no reports of cases in which a drainage catheter in the ventricle was removed using a flexible endoscope. This case suggests that a flexible endoscope is useful for removing a foreign body from the ventricle less invasively.

ASYMPTOMATIC SHUNT FRACTURE IN A PATIENT WITH HISTORY OF TUBERCULOUS MENINGOENCEPHALITIS: A CASE REPORT.

Ventriculoperitoneal (VP) shunt is the most frequently performed procedure in patients with hydrocephalus, but can cause seri¬ous complications. Shunt fractures, is a rare complication of VP shunt and can be damage for patient. The question of whether asymptomatic patients should or should not be operated on remains to be answered. The authors report a case of a pediatric patient who had an asymptomatic shunt fracture with a history of tuberculous menin¬goencephalitis (TBM). We report the case of a 7-year-old girl with a shunt fracture and a history of hydrocephalus due to TBM. She presented to the hospital in 2021 without symptoms of increased intracranial pressure and was fully conscious. Three weeks later, the patient experienced a gradual loss of consciousness. The result of the examination revealed that the hydrocephalus had become larger than before the operation in 2015. The peritoneal shunt had completely migrated into the peritoneal cavity. An emergency shunt revision was performed at the left Kocher point. After the operation, the patient regained consciousness and lived life without any complications. Although the decision to re-operate in an asymptomatic patient with a shunt fracture is debatable, shunt revision should be con¬sidered. Early revision of the shunt fracture does not pose a serious hazard to the patient.

Management of Hydrocephalus in Children: Anatomic Imaging Appearances of CSF Shunts and Their Complications.

OBJECTIVE. This article addresses the management of hydrocephalus and the CSF shunts used to treat this entity. CONCLUSION. CSF shunts have a high failure rate. Imaging plays a pivotal role in assessing CSF shunt failure and determining the need for surgical revision. An in-depth knowledge of CSF shunt components, their failure modes, and the corresponding findings on anatomic imaging studies is necessary to ensure timely diagnosis and prevent permanent neurologic damage.

"Shunt pumping test": detecting its efficacy through an experimental model.

PURPOSE: Shunt pumping test has often been used clinically to detect functional status of ventriculoperitoneal (VP) shunt. Its ability to correctly predict the status is not reliably known. Ethical dilemmas make it difficult to perform any studies in patients with blocked shunts, and hence, a requirement of devising an experimental model was felt. METHOD: An experimental model was devised using a Chhabra Slit N Spring shunt. The pressures were maintained in the proximal and distal chamber by real-time monitoring and maintained similar to intra-ventricular and intra-abdominal pressures. Three such models with scenarios of proximal block (PB), distal block (DB), and a functional shunt (BO) were created. Twenty-five participants were tested using these models to assess the efficacy of shunt pumping test. RESULTS: The experimental model could be used successfully to perform the test. The sensitivity of the test to detect a shunt with block on any side (AB) was found to be 0.79 (95% confidence interval 0.72-0.85) and specificity to be 0.69 (95% confidence interval 0.59-0.80). Its ability to detect the side of block was also evaluated. Absolute correctness value, odds ratio, and interpersonal heterogeneity were also evaluated. Pressure changes in proximal and distal catheter on compressing the chamber in various scenarios were recorded. CONCLUSION: The shunt pumping test has moderate ability to predict a blocked shunt and can aid clinical assessment of shunt block. It has only limited ability to detect the side of block. Pressure changes in the proximal and distal catheters on chamber compression are commensurate with the rationale of "shunt pumping test."

Bowel perforation of ventriculoperitoneal shunt catheter: endoscopically treated two cases.

PURPOSE: Many techniques were used for the treatment of hydrocephalus, and ventriculoperitoneal shunt surgery is a widely used procedure. Ventriculoperitoneal shunt surgery has been associated with several complications like obstruction of the tube, infection, cerebrospinal fluid loculation, intestinal obstruction, migration of the shunt, and perforation of the intestinal organs. Perforation of the bowel owing to protrusion of ventriculoperitoneal shunt catheter from the anus is an extremely rare complication. Mini or exploratory laparotomy and revision of peritoneal part of shunt and repair of bowel perforation, or pulling out the ventriculoperitoneal shunt catheter and using external ventricular drainage and antibiotics, or colonoscopic removal of ventriculoperitoneal shunt catheter and repair of the bowel can be performed. Retrograde contamination of cerebrospinal fluid and meningitis is a very important part of the treatment in these cases. We aimed to present two cases with bowel perforation who treated with endoscopically. METHODS: We report the cases of 2 patients with transanal protrusion of VPS catheter and the management via endoscopic therapeutic options. RESULTS: Successful treatment of the patients was achieved by endoscopic removal of the catheter and endoscopic repair of the bowel perforation. CONCLUSION: If peritonitis, bowel obstruction, or abscess does not occur, endoscopic removal of shunt and bowel repairing with endoclips may be enough.

Revision and complication rates in adult shunt surgery: a single-institution study.

BACKGROUND: CSF diversion with shunt placement is frequently associated with need for later revisions as well as surgical complications. We sought to review revision and complication rates following ventriculoperitoneal, ventriculoatrial and cystoperitoneal shunt placement in adult patients, and to identify potential risk factors for revision surgery and postoperative complications. METHOD: Included patients were adults (≥ 18 years) who underwent primary shunt insertion at St. Olavs Hospital in Trondheim, Norway, from 2008 through 2017. The electronic medical records and diagnostic imaging from all hospitals in our catchment area were retrospectively reviewed. Follow-up ranged from 1 to 11 years. Complications were graded according to the Landriel Ibañez classification system. RESULTS: Of the 227 patients included, 47 patients (20.7%) required revision surgery during the follow-up. In total, 90 revision surgeries were performed during follow-up. The most common cause for the first revision was infection (5.7%) and for all revisions proximal occlusion (30.0%). A total of 103 patients (45.4%) experienced ≥ 1 complication(s). Mild to moderate complications (grade I and II) were detected in 35.0% of all procedures. Severe or fatal complications (grade III and IV) were observed in 8.2% of all procedures. Urinary tract infections and pneumonia were common postoperatively (13.9% and 7.3%, respectively), and the most common IIb complication was shunt misplacement (proximally or distally). Two out of fourteen deaths within 30 days were directly associated with surgery. We did not find that aetiology/indication, age or gender influenced the occurrence of revision surgery or a grade III or IV complication. CONCLUSIONS: Shunt surgery continues to be a challenge both in terms of revision rates and procedure-related complications. However, the prediction of patients at risk remains difficult. A multidimensional focus is probably needed to reduce risks.

Perinatal Outcome in Fetuses with Dislodged Thoraco-Amniotic Shunts.

OBJECTIVE: Fetal thoraco-amniotic shunts (TASs) can dislodge in utero, migrating internally into the fetal thorax or externally into the amniotic cavity. Our objective was to evaluate the perinatal and long-term outcome of fetuses with TAS dislodgement and conduct a review of the literature. METHODS: This is a retrospective review of all TAS inserted for primary pleural effusions and macrocystic congenital pulmonary airway malformations (CPAMs) in a tertiary fetal medicine center (1991-2020). Antenatal history, procedural factors, and perinatal and long-term outcomes were reviewed in all fetuses with dislodged shunts and compared to fetuses with shunts that did not dislodge. RESULTS: Of 211 TAS inserted at a mean gestational age of 27.8 weeks ± 5.47 (17.4-38.1 weeks), 187 (89%) were inserted for pleural effusions and 24 (11%) for macrocystic CPAMs. Shunts dislodged in 18 fetuses (8.5%), 17 (94%) of which were for pleural effusions. Shunts migrated into the chest wall/amniotic cavity or into the thorax among 7/18 (39%) and 11/18 (61%) fetuses, respectively. Eleven (61%) fetuses were initially hydropic, which resolved in 8 (72%) cases. Effusions were bilateral in 9 (50%), amnioreduction was required in 6 (33%), and fetal rotation in 8 cases (44%). Four (22%) fetuses underwent repeat shunting, 12 (67%) neonates required ventilatory support, and 2 (11%) neonates required chest tubes. There was no significant difference in technical factors or outcomes between infants with shunts that dislodged and those that did not. Among 11 intrathoracic shunts, 2 (18%) were removed postnatally and the remainder are in situ without any shunt-related or respiratory complications over a follow-up period of 9 months to 22 years. CONCLUSION: TAS dislodged antenatally in 8.5% of fetuses, with 2/3 of shunts migrating into the thorax, and nearly 25% requiring re-shunting. Retained intrathoracic shunts were well tolerated and may not necessarily require surgical removal after birth.

Shunt migration in ventriculoperitoneal shunting: A comprehensive review of literature.

Ventriculoperitoneal shunts are one of the commonest surgical procedures performed in neurosurgery. Complications of this procedure include mechanical complications and nonmechanical ones. The most distressing mechanical complication is shunt migration, and often when this occurs, it becomes difficult to work out the mechanism and the management protocol. This review is designed to answer questions regarding management details of this unfortunate complication, and also seeks to identify the causes.

Diffuse large B-cell lymphoma: a rare complication of an abdominal CSF pseudocyst.

Abdominal CSF pseudocysts are an uncommon complication of ventriculo-peritoneal shunting. We report the case of a 35 year old man with a myelomenigocele, associated Chiari 2 malformation, and VP shunt developing a Diffuse Large B-Cell Lymphoma within the lining of an abdominal CSF pseuodcyst. This diagnosis should be considered in those with recurrent pseudocysts, or those associated with a swinging pyrexia and high C-Reactive protein, in the absence of infection.

A new shunt for obstructive hydrocephalus: ventricle-Sylvian fissure shunt A preliminary report.

Cerbrospinal fluid (CSF) pathway studies have revealed that after egressing from the fourth ventricle reaches the basal supra sellar cistern and ultimately the sylvian cisterns from where the CSF travels over the cerebral convexity subarachnoid space to reach the superior saggital sinus and enters the blood stream. Diverting CSF from the lateral ventricle with a shunt catheter to the sylvian cistern can be an option to treat obstructive hydrocephalus. 2 patients underwent this procedure of diverting CSF from the lateral ventricle with a shunt catheter (Chabbra, India) to the sylvian cistern successfully and had immediate relief of symptoms of raised intracranial pressure. Additional 4 patients had relief for 3mths to 6 mths and are under follow up. Though preliminary results seem logical and promising, more cases and longer follow-up is required to consider this shunt operation as an option in treatment of obstructive hydrocephalus.

Iatrogenic syringomyelia secondary to lumboperitoneal shunt altered by the raised intra-abdominal pressure of pregnancy.

We report a case of a 37 year old female with syringomyelia secondary to lumboperitoneal (LP) shunt. Syrinx regression occurred with raised intra-abdominal pressure due to pregnancy and subsequently redeveloped after parturition. To our knowledge a case of pregnancy associated syringomyelia regression has not been previously reported.

Gravity-assisted valve (GAV) systems to prevent low-pressure headaches in patients with lumboperitoneal shunts.

OBJECTIVES: Low-pressure symptoms after lumboperitoneal (LP) shunting for idiopathic intracranial hypertension (IIH) remain a significant problem. Gravity-assisted valves (GAV) operate at a higher pressure in a vertical position and therefore aim to reduce postural over-drainage. We audited patients with GAV valves inserted in their shunt system to assess their efficacy in reducing low-pressure symptoms and ascertain whether the additional cost of such device can be justified. METHOD: Using a standard proforma, we reviewed patient medical notes and recorded indications and post-operative outcomes in symptom control. RESULTS: In total, 24 patients had the GAV system inserted, 12 had low-pressure symptoms after LP and had LP shunts inserted with GAV valves and 11 in developed low-pressure symptoms after insertion of plane LP shunts and had GAV valves added as secondary procedures. One patient was excluded from the study because the indication for the GAV system was secondary to the presence of low lying cerebellar tonsils (secondary Chiari) rather than headache in a patient with IIH who had undergone previous LP shunt insertion. The GAV system was introduced to prevent further tonsillar decent.Out of 23 patients, 17 patients who had the system inserted to prevent or improve low-pressure symptoms reported improvement in their symptoms. CONCLUSIONS: GAV inserted into LP shunts were effective in reducing low-pressure headaches induced by changes in posture whilst still sufficiently lowering ICP to ameliorate high-pressure symptoms.

[Shunt-induced craniosynostosis: topicality of the problem, choice of the approach, and features of surgical treatment]. / Shunt-indutsirovannyi kraniosinostoz: aktual'nost' problemy, vybor taktiki, osobennosti khirurgicheskogo lecheniia.

RATIONALE: Shunt-induced craniosynostosis is one of the late complications of CSF shunting surgery, which affects the patient's condition, clinical picture, and treatment approach. OBJECTIVE: to evaluate the prevalence rate and clinical significance of this disease, define the indications for surgery, and choose the optimal surgical approach. MATERIAL AND METHODS: The study included 59 children with shunt system dysfunction, aged 1 to 14 years, who were treated at the Department in the period from 2014 to 2016. The inclusion criteria were as follows: 1) age at the time of examination is older than 1 year; 2) implantation of a shunt system in the first 12 months of life. The state of cranial sutures was assessed using three-dimensional reconstruction of patient's computerized tomography images. Images obtained before or in the first months after primary implantation of a shunt system were used to exclude cases of primary craniosynostosis. RESULTS: Premature synostosis of the cranial sutures was detected in 27 (46%) cases. Of these, 3 (11%) patients with clinical symptoms of increased intracranial pressure and radiographic signs of craniocerebral disproportion underwent cranial vault remodeling surgery: two biparietal craniotomies and one fronto-parieto-occipital reconstruction. In two cases, simultaneous replacement of a valve with a programmable one was performed. There were no complications after reconstructive surgery. CONCLUSION: Shunt-associated craniosynostosis is one of the late complications of CSF shunting surgery. However, its presence is not an indication for surgery and should not be a reason for surgical aggression. Surgery for increasing the intracranial volume is indicated only for secondary craniosynostosis combined with signs of craniocerebral disproportion. In these cases, reconstructive surgery is an effective treatment option for improving the patient's condition.

Pericardial effusion and cardiac tamponade after ventriculoperitoneal shunt placement: a case report.

Insertion of a ventriculoperitoneal shunt is a common neurosurgical procedure in both adult and paediatric patients. It is one of the most important treatments in cases of hydrocephalus; however, there is a wide range of complications: the most common complication being a shunt infection, and examples of rare complications are shunt migrations and cardiac tamponade. Several reports of distal ventriculoperitoneal shunt migration in different sites, including chest, right ventricle, pulmonary artery, bowel and scrotum were published. But pericardial effusion with cardiac tamponade and its relationship to distal ventriculoperitoneal shunt migration into the pericardial sac has never been reported.

Neuronavigation as a diagnostic tool: An innovative application.

The role of neuronavigation in tumour surgery is well established. We present an innovative use for this software, as a tool to compare ventricular size between serial sets of cranial imaging. We conclude that neuronavigation software is potentially a powerful diagnostic tool that should not be overlooked when making comparative assessments between scans.

Scrotal Migration of the Ventriculoperitoneal Shunt: A Case Report and Review of the Literature.

Ventriculoperitoneal (VP) shunt placement is the most frequently used treatment for hydrocephalus. This procedure is not always free of complications, and patients may need additional surgeries to overcome these complications. We are presenting the case of a seven-month-old baby who underwent myelomeningocele repair and VP shunt placement 13 days ago and now presents with inguinal swelling extending into the scrotum. The radiological workup revealed that the peritoneal end of the VP shunt had migrated to the scrotum, causing hydrocele. The shunt was relocated to the abdomen after a right herniotomy and sac reduction. He was discharged on the second postoperative day without any complications, and the further recovery was good at three months. Scrotal migration of a VP shunt is a rare complication and can be avoided by careful early assessment of inguinal hernia or patent processus vaginalis and its surgical repair.