Shunt Dysfunction Assessment in Shunted Patients via Multiparametric Non-Invasive ICP Waveform Monitoring

BACKGROUNDThe authors report a case of a patient with normal-pressure hydrocephalus treated with a ventriculoperitoneal shunt who developed a traumatic hemispheric bilateral acute subdural hematoma caused by quick cerebrospinal fluid (CSF) overdrainage. The authors present active ventricular CSF volume restoration as a novel treatment option. CSF overdrainage in patients with shunts may facilitate acute subdural hematoma formation even in cases of minor head trauma. Therapeutic options include CSF shunt function restriction or ligation, hematoma evacuation, or a combination of both.OBSERVATIONSIn this case, the authors performed emergency surgery with hematoma evacuation through a bilateral craniotomy and actively restored the volume of the ventricular system with a slow intraventricular injection of 37°C warmed Ringer solution through a shunt burr hole reservoir.LESSONSIn addition to hematoma evacuation and restriction of shunt function, the intraoperative restoration of ventricular volume could be a treatment option to prevent postoperative rebleeding or a space-occupying air collection in the subdural space. The risk of possible complications, such as ventricular or parenchymal bleeding, shunt dysfunction, or infections, requires further investigation. Restoration of the ventricular CSF volume by intraventricular injection of Ringer solution was in this case an efficient treatment method to prevent subdural rebleeding and a space-occupying air collection after subdural hematoma evacuation.

Laparoscopic fundoplication in children with previous abdominal surgery

Many COVID-19 infected people remain asymptomatic, and hence the diagnosis at first presentation remains a challenge. Assessment at a presentation in primary care settings is usually done by visual triaging and basic clinical examination. This retrospective study involved investigating the medical e-records of COVID-19 positive patients who presented to a COVID-19 centre in Qatar for July 2020. The presence (symptomatic group) or the absence (asymptomatic group) of symptoms along with objective vital examination ( ie ; heart-rate (HR), temperature, haemoglobin saturation (SpO2)) were analysed and linked to the viral load ( ie ; cycle threshold (Ct)) of COVID-19 positive patients. Four hundred eighty-one symptomatic (230 males) and 216 asymptomatic (101 males) patients were included. Compared to the asymptomatic male group, the symptomatic male group was older, had lower Ct value and SpO2, and higher temperature and HR. Compared to the females asymptomatic group, the symptomatic females group had lower Ct value, and higher temperature. Compared to the asymptomatic group, the symptomatic group had lower Ct value and SpO2, and higher temperature and HR. Compared to the asymptomatic group, the symptomatic group had lower Ct values (age groups [21–30], [31–40], [41–50] and [51–60]), higher temperature (age groups [21–30] and [31–40], Ct ranges [20.01–25.00] and [25.01–30.00]), higher HR (age groups [21–30] and [31–40], Ct range [15.01–20.00]); and lower SpO2 (age groups [41–50] and [51–60], Ct ranges [15.01–20.00] and [35.01–40.00]). Compared with asymptomatic patients, symptomatic patients with COVID-19 are most likely to be febrile, tachycardic, hypoxic and having higher viral load. Higher viral load was associated with higher HR, higher temperature, lower SpO2, but there was no relation between viral load and age.

Aim: Ventriculoperitoneal (VP) shunt surgery is the most widely accepted method for the treatment of hydrocephalus. Shunt dysfunction is a common complication with various etiologies. This study aimed to evaluate pediatric patients who underwent surgery due to shunt dysfunction during the pandemic period and were COVID-19 positive in the preoperative period. Material and Methods: The findings of the patients who underwent surgical treatment with a preliminary diagnosis of shunt dysfunction between March 2020 and 2023 were examined in the present study. A retrospective cross-sectional design was adopted. Age, sex, date of COVID-19 positivity, symptoms at presentation, CSF findings, CSF culture, blood tests, and applied treatments of the patients were obtained from patient files and electronic records. Results: Among 13 pediatric patients with VP shunt dysfunction and preoperative COVID-19 positivity, fever (61.5%) and decreased sucking/restlessness (62.5%) were the most frequent symptoms. Two patients had positive CSF cultures. Biochemical abnormalities were observed, including elevated D-dimer and transaminases. Conclusion: COVID-19 may contribute to shunt dysfunction through gastrointestinal and peritoneal involvement, even in the absence of respiratory symptoms. Clinicians should maintain high suspicion for shunt malfunction in pediatric patients with COVID-19 and hydrocephalus.

Pneumocephalus is defined as the presence of intracranial air and is a rare but potentially significant complication following ventriculoperitoneal (VP) shunt placement. Delayed presentations are uncommon and remain poorly described in the literature. The report demonstrates the case of a 74-year-old male patient who developed delayed spontaneous intraventricular pneumocephalus 10 months after VP shunt insertion in September 2022 using a high-pressure fixed valve for obstructive hydrocephalus secondary to a tectal plate lesion. The patient presented in July 2023 with posture-dependent frontal headache, tinnitus, and bruit hydroaérique, without fever, infection, or neurological deterioration. Computed tomography revealed intraventricular air and a small air focus adjacent to the mastoid tegmen, suggestive of an occult skull base defect. The presumed mechanism involved sustained negative intracranial pressure related to the siphon effect of the shunt system, facilitating air entry through a pre-existing osteodural defect. Given the patient's clinical stability and absence of infection or shunt malfunction, a conservative management strategy was adopted. Complete clinical and radiological resolution was observed within two weeks, with no recurrence during 12 months of follow-up. This case highlights a rare delayed complication of VP shunting and demonstrates that conservative management may be a safe and effective option in carefully selected, clinically stable patients, after exclusion of infection and shunt dysfunction. It contributes to the limited existing literature on non-invasive treatment strategies for delayed pneumocephalus.

Results ICPM was undertaken for a number of different conditions including undiagnosed headache (20.4%), IIH (28.7%), NPH (5.3%), high-pressure hydrocephalus (eg congenital/ post-traumatic/post-SAH) (17.2%) and Chiari malformations/syringomyelia (13.6%). Indications for ICPM included headache (74.0%), visual disturbance (6.2%), gait disturbance (6.2%) and cognitive disturbance (5.0%). Mean monitoring time was 37.3 hrs (range 12-154 hrs). Monitoring was conducted in the presence of a CSF shunt (50.6%), venous stent (3.7%) and previous cranial decompression (6.5%). Dynamic monitoring (eg with different shunt settings or pre/post venous stent insertion) was undertaken in 12.4%. Outcomes from ICPM included insertion of new CSF shunt (21.0%), revision of CSF shunt (13.0%), insertion of venous stent (6.5%), insertion of and lumbar drains for infusion studies (3.6%); importantly, non-operative treatment was pursued in a number of cases including shunt valve adjustment (7.7%) and conservative management (29.9%). Complications included superficial infection (4 patients, 1.2%), symptomatic intracerebral haematoma (1 patient, 0.3%) and misplacement (3 patients, 0.9%); importantly, there were no cases of deep intracranial infection and the only case of seizures was in the patient with the intracerebral haematoma. Conclusion This is the largest known series of ICPM for CSF disorders. It shows that ICP monitoring is a safe procedure and may be undertaken as part of routine protocol in the management of complex hydrocephalus patients. The number of cases that were subsequently managed conservatively or with a simple valve adjustment (37.6%) indicates the utility in terms of reducing operative interventions. Further evaluation of positive and negative predictive values based on the results of ICP monitoring and health-economic analyses will push the case for routine ICP monitoring prior to definitive management of all hydrocephalus patients.

Ventriculoperitoneal shunt surgery and the incidence of shunt revision in adult patients with hemorrhage-related hydrocephalus

Background and aimsWhether asymptomatic patients with colorectal cancer (CRC) who are treated in hospitals show better outcomes than symptomatic patients with CRC still remains unknown. The aim of this study...

OBJECT Patients with CSF shunts are medically complex and frequently present to the emergency department (ED) with suspected shunt malfunction. After adequate evaluation in the ED and proper disposition, some patients return to the ED within a short period of time. In this study, the authors examined the reasons for ED revisits within 7 days of the index ED visit to discern possible preventable returns. METHODS There were 3080 index ED visits made by patients with shunted hydrocephalus between 2010 and 2013. Index ED visits preceded by another ED visit or neurosurgical procedure within 60 days were excluded. Index ED visits for reasons unrelated to shunt function and those that led directly to admissions and shunt revision surgeries were also excluded. The remaining 1509 ED visits were eligible for analysis in this study. Final dispositions from the index ED visit included home (1176 cases), admission to the neurosurgery service for observation (134 cases), and admission to other services (199 cases). Subsequent events within 7 days, including ED revisits, hospital admissions, and shunt-related surgery were recorded, and reasons for the ED revisits were categorized based on whether the visit was related to shunt function concerns. Clinical and socioeconomic factors were analyzed for their association with ED revisits by using statistical methods. RESULTS Of the 1176 patients discharged home from the ED after shunt function evaluation, 101 (8.6%) returned to the ED within 7 days. Of the 134 patients admitted to the neurosurgery service for observation only, 8 (6.0%) returned to the ED within 7 days of discharge. Of the 199 patients admitted to hospital services other than neurosurgery, 13 (6.5%) returned to the ED within 7 days of discharge. The reasons for ED revisits vary (total of 122 visits combining the 3 groups), but at least 60% of the revisits were clearly unrelated to shunt function. A younger age, daytime arrival to the ED, and living within the metropolitan area were identified as risk factors for ED revisits. CONCLUSIONS Children with CSF shunts are medically complex and use ED services often. After an index ED visit at which shunt function was deemed to be the chief concern, the purpose of the subsequent return to the ED within 7 days was often for complaints unrelated to shunt function. Caution is warranted when attempting to classify these complex patients as having potential preventable return-to-system events.

BackgroundThe most common treatment of hydrocephalus is ventriculoperitoneal shunt (VPS) operation. Shunt dysfunction may develop in patients with ventriculoperitoneal shunt. The most common causes of shunt dysfunction, which are more common in pediatric patients, are infection, obstruction, visceral injury, pseudocyst formation, and excessive or inadequate drainage. Shunt migration is a rare complication of VPS operation, and the shunt catheter may migrate to the gastrointestinal tract, scrotum, bladder, and other organs. Revision surgery is a safe treatment option in most cases of shunt dysfunction or migration.Case presentationIn this report, a 2-year and 10-day-old baby patient was observed to have bilateral hydrocele in the outpatient clinic follow-up after the VPS operation, and after radiological imaging, it was determined that the shunt peritoneal catheter was in the scrotum. The patient underwent shunt revision surgery.ConclusionAlthough malposition of the VPS peritoneal catheter is not always an emergency, reinsertion and surgical revision should be done promptly due to the risk of perforation due to malposition. Close follow-up of patients with VPS is important for early diagnosis and treatment of complications.

The exact underlying mechanism for the differential clinical profiles of symptomatic and asymptomatic primary hyperparathyroidism (PHPT) patients has not been fully elucidated, and efforts to define the molecular mechanisms underlying the phenotypic heterogeneity of PHPT have been limited. The aim of this study was to explore the underlying molecular mechanisms involved in the pathogenesis of symptomatic and asymptomatic sporadic PHPT in Asian Indians. A prospective cohort study was conducted at a tertiary care hospital in North India. PHPT patients who underwent parathyroidectomy were included. The main outcome was the comparison of vitamin D receptor (VDR), calcium-sensing receptor (CaSR), cyclin D 1 (CD1), and parathyroid hormone (PTH) mRNA levels between symptomatic and asymptomatic PHPT patients and controls determined via quantitative real-time polymerase chain reaction (qRT-PCR). Forty-two PHPT patients were studied. The mean (SD) age was 49.7 (12.8) years. Twenty patients were asymptomatic. The median PTH levels were significantly greater in the symptomatic group than in the asymptomatic group (878 vs 653 pg/mL). CaSR and VDR mRNAs were significantly lower in both symptomatic and asymptomatic patients than in controls. CD1 and PTH mRNAs were significantly increased in symptomatic patients, but not in asymptomatic PHPT patients compared with controls. Symptomatic PHPT patients had significantly greater CD1 mRNA expression and reduced CaSR expression than asymptomatic patients. Symptomatic PHPT patients had significantly greater CD1 mRNA expression and lower CaSR expression than asymptomatic patients, underscoring the importance of the molecular mechanisms underlying the phenotypic heterogeneity of PHPT.

BackgroundPreviously, the sagittal spinal balance in both asymptomatic and scoliotic Caucasian people has been characterized and compared. Very recently, the sagittal spino-pelvic parameters among asymptomatic Chinese adults have been studied, and the results were compared with Caucasian adults, indicating that a difference did exist. Unfortunately, the distribution of sagittal standing posture patterns among the Chinese population has not been characterized in either asymptomatic or scoliotic groups.MethodsWe conducted a radiographic comparison study to define the deviation of sagittal balance in scoliotic patients from that of an asymptomatic population. A total of 126 asymptomatic and 117 idiopathic scoliotic (IS) young adults were recruited. Radiographic data from each subject were reviewed, and sagittal spinopelvic parameters were measured. The Roussouly type was then determined, as well as the relative position of the C7 plumbline with respect to the sacrum and hip axis. Comparison analyses were undertaken between the two different groups.ResultsThe IS group had a larger pelvic incidence, pelvic tilt and sacral slope, but a smaller spinal tilt than the asymptomatic group (P < 0.05), while other sagittal parameters were similar. The distribution of Roussouly types was similar between the asymptomatic and IS groups, of which 49.2% and 45.3% belonged to Roussouly Type 3, respectively. Asymptomatic males and females had a similar distribution, which was different between the two genders in the IS group (P < 0.05), with more females possessing a neutral sagittal standing posture. In addition, more IS subjects had forward displacement of the C7 plumbline than asymptomatic ones (P < 0.05), while there was no difference between the two genders in either group.ConclusionsAlthough sagittal pelvic parameters were greater in the IS population, their sagittal spinal balance was maintained and there was no sagittal standing posture pattern correlated with IS. The occurrence of anterior displacement of the C7 plumbline was more common in IS patients than asymptomatic adults, but did not appear to be correlated with gender in both populations.

Stenotrophomonas maltophilia is an extremely rare pathogen responsible for ventriculoperitoneal shunt infection and meningitis. This young female patient with history of multiple shunt revisions in the past, came to us with shunt dysfunction and exposure of the ventriculoperitoneal shunt tube in the neck. The abdominal end of the shunt tube was seen migrating into the bowel during shunt revision. The cerebrospinal fluid analysis showed evidence of Stenotrophomonas maltophilia growth. This is the first reported case of Stenotrophomonas maltophilia meningitis associated with ventriculoperitoneal shunt migration into the bowel.

Laparoscopic Treatment of Ventriculoperitoneal Shunt Complication Caused by Distal Catheter Isolation Inside the Falciform Ligament

Modularity in total hip arthroplasty facilitates intraoperative restoration of patient anatomy. Although dual-taper modular total hip arthroplasty offers potential advantages for optimizing the hip center of rotation, it has been associated with modular taper corrosion. This corrosion has led to adverse local tissue reactions (pseudotumors) at the neck-stem junction and elevated metal-ion levels. However, the occurrence of taper-corrosion-related pseudotumors in patients who remain asymptomatic following total hip arthroplasty with a dual-taper modular femoral stem remains largely unknown. The aims of this study were (1) to determine the prevalence of asymptomatic pseudotumors by utilizing metal artifact reduction sequence magnetic resonance imaging (MARS-MRI) and (2) compare serum metal-ion levels between symptomatic and asymptomatic patients with a dual-taper modular stem total hip replacement. We performed a retrospective cross-sectional study of 97 consecutive patients who had been treated with a dual-taper modular femoral stem total hip arthroplasty. Eighty-three patients were stratified into symptomatic and asymptomatic groups and evaluated with MARS-MRI, measurement of serum metal-ion levels, and the University of California at Los Angeles (UCLA) functional hip score. The prevalence of pseudotumors as determined with MARS-MRI was 15% in our asymptomatic patients and 36% in the overall cohort. The median serum cobalt level and cobalt/chromium ratio were significantly higher in patients with a pseudotumor than in those without a pseudotumor (8.0 versus 2.0 μg/L [p = 0.004] and 10.3 versus 2.4 μg/L [p = 0.012], respectively). However, there was no significant difference in the serum cobalt level or cobalt/chromium ratio between symptomatic patients with a pseudotumor and asymptomatic patients with a pseudotumor (7.6 versus 6.2 μg/L [p = 0.37] and 8.3 versus 10.6 μg/L [p = 0.46], respectively). The UCLA scores of asymptomatic patients with a pseudotumor were similar to those of patients without a pseudotumor (6.7 versus 6.6). The prevalence of asymptomatic taper-corrosion-related pseudotumors on MARS-MRI in this study demonstrated that the absence of symptoms does not exclude the presence of adverse local tissue reactions. Elevated cobalt levels and cobalt/chromium ratios were associated with the presence of pseudotumors in asymptomatic and symptomatic patients. Cross-sectional imaging such as MARS-MRI is indicated for patients with elevated metal-ion levels. A longitudinal study is required to determine whether asymptomatic patients with taper-corrosion-related pseudotumors will develop symptoms with time. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.