Congenital: TORCH, X-linked, cysts, developmental(e.g. venous outflow obstruction or webs)
Acquired: IVH, infectious, traumatic, tumors
PRESENTATION IN INFANCY
Rapid Skull Growth
Full Fontanelle
Split Cranial Sutures
Poor Feeding
Irritability
Apnea
Bradycardia
Macrocephaly
Setting Sun Sign
PRESENTATION IN - CHILDREN AND ADULTS
Head-ache
Nausea and Emesis
Alteration in Level of Consciousness
Behavioral Changes
Worsening Work/School Performance
Spasticity
Papilledema
Irritability
NORMAL PRESSURE HYDROCEPHALUS
At first, the symptoms in normal pressure hydrocephalus are usually very subtle. They worsen very gradually.
Dementia symptoms
Memory loss
Speech problems
Apathy (indifference) and withdrawal
Changes in behavior or mood
Difficulties with reasoning, paying attention, or judgment
Walking problems
Unsteadiness
Leg weakness
Sudden falls
Shuffling steps
Difficulty taking the first step, as if feet were stuck to the floor
“Getting stuck” or “freezing” while walking
Urinary symptoms
Inability to hold urine
Inability to hold stool, or feces (less common)
Frequent urination
Urgency to urinate
TREATMENT OPTIONS
VENTRICULO-PERITONEAL SHUNT
THIRD VENTRICULOSTOMY
VENTRICULOATRIAL SHUNT
OTHER DIVERSIONARY SHUNTS
MEDICATIONS (SHORT TERM REDUCTION OF CSF PRODUCTION WITH ACETAZOLAMIDE)
VALVE OPTIONS
PRESSURE CONTROLLED
FLOW REGULATED
ANTI-SIPHON DEVICE
PROGRAMMABLE
PRE-OP MRI - of Acqueductal Stenosis
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OR POSITIONING
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OR PREP
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PASSING THE SHUNT
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VENTRICULAR CATHETER
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VENTRICULAR CATHETER
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PERITONEAL TROCHAR
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PERITONEAL CATHETER
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SHUNT COMPLICATIONS
SHUNT OBSTRUCTION ‐ UP TO 40% IN 3 MONTHS
SHUNT INFECTION ‐ 3-5%, HIGHER IN PREMATURE INFANTS OR WITH CONCURRENT INFECTION
SEIZURES - >30% INCIDENCE OF EPILEPSY
SLIT VENTRICLE SYNDROME
SECONDARY SYNOSTOSIS
SUB-DURAL HEMATOMA
BRAIN INJURY ‐ 1/40,000
WOUND DEHISCENCE
EVALUATION OF SHUNT INFECTION
History ‐ Fever, chills, N/V, redness around incision, revision<6months ago
Examination ‐ Fever, tachycardia, dehydration, drainage or erythema about shunt, peritoneal or meningeal signs
Radiology doesn't assist in the diagnosis of shunt infection
Lab work ‐ CBC with diff, CSF from shunt tap for glucose, protein, cell counts, gm stain & cx
TREATMENT OF SHUNT INFECTION
Antibiotics alone are not adequate
Shunt must be removed and, usually, CSF must be externally drained(as an abscess) while anti-biotics are ongoing
Need 3 negative cultures prior to re-implantation
Try to replace shunt on opposite side
Risk of infection now twice rate of previously uninfected
EVALUATION OF SHUNT FAILURE
LISTEN TO THE PATIENT AND FAMILY
History ‐ head-aches, N/V, poor feeding, lethargy, swelling around shunt
Examination ‐ fontanelle, papilledema, level of consciousness, lack of other sources, e.g. flu
Radiology ‐ head CT and shunt series(comparison films are essential)
If fear of shunt failure continues, shunt tap
If good flow but still concerned, abdominal ultrasound vs CT
TREATMENT OF SHUNT FAILURE
Surgery is only option
Replacement of failed part
Or
3rd ventriculostomy in appropriate patient
CT COMPARISON
INFECTION RATES
Ventriculo-peritoneal shunts are the most commonly infected implants in neurosurgery and among the most commonly infected implants in any specialty
Shunt infection rates have varied from 0-75% in previous publications
OUTCOMES BASED MEDICINE
KNOWN RISK FACTORS THAT INCREASE VENTRICULO-PERITONEAL SHUNT INFECTION RATES
Age1
Associated Diagnoses2
Antibiotic Prophylaxis3
Length of Hospital Stay4
Tuli et al J Neurosurg. 2004 May;100(5 Suppl Pediatrics):442-6
Vinchon et al Childs Nerv Syst. 2006 Jul;22(7):692-7.
Pattavilakan et al J Clin Neurosci. 2007 Jun;14(6):526-31.
CID 2003:36 (1 April) · McGirt et al.
POSSIBLE RISK FACTORS THAT INCREASE VENTRICULO-PERITONEAL SHUNT INFECTION RATES
Time of Day Procedure Starts
Duration of Surgery
Number of Assistants
Use of Home Laundered Scrubs
Experience of Surgeon
METHODS
Prospective patient data collection was performed using hospital and practice data bases.
Literature review was used to create the shunt protocol.
SHUNT PROTOCOL
MINIMIZE SURGICAL PERSONNEL(<4)
NO SURGICAL ASSISTANCE
MINIMIZE SURGICAL TIME(<15 MINUTES)
USE UNITIZED ANTI-BIOTIC IMPREGNATED SHUNT(BACTISEAL SHUNT WAS USED, WITH 70 OR 100mmHg FIXED PRESSURE VALVES IN MOST CASES)
MINIMIZE USE OF PROGRAMMABLE VALVES
PERFORM SHUNTS AS FIRST CASE, IN TERMINALLY CLEANED ROOM, WHEN POSSIBLE
USE NEURO TEAM(RN AND TECH), WHEN POSSIBLE
RESULTS: PATIENT VARIABLES
NO STATISTICALLY SIGNIFICANT VARIATION IN ANY OF THE ABOVE
RESULTS: PROTOCOL VARIABLES
RESULTS: INFECTION RATES
CONCLUSION
With stringent adherence to a strict protocol, <2% ventriculo-peritoneal shunt infection rate is an attainable mark.
0% should be our goal.
WHERE DO WE GO FROM HERE?
First described in Dandy WE: An operative procedure for hydrocephalus. Johns Hopkins Hosp Bull 33:189‐190, 1922
Endoscopic 3rd ventriculostomy is gaining popularity due to minituarization and improved optics.
However, there is a significant learning curve, both for the surgeon and the OR staff concerning the procedure.
It is one of the few procedures in neurosurgery in which the surgeon may not be able to immediately control bleeding.
3RD VENTRICULOSTOMY
Benefits: Shunt independence
Minimal risk of infection
Reduced failure rate in selected patients
Risks: Injury to the basilar artery
Failure to make adequate hole(closure)
Forniceal injury(memory)
WHO ARE THE RIGHT PATIENTS FOR A 3RD VENTRICULOSTOMY?
Obstructive hydrocephalus
Spina Bifida
Tumor
Acqueductal stenosis
No infection/injury to arachnoid granulations
Big enough head to allow for navigation(over 2 years of age)
ANATOMY
ENDOSCOPE WITH FOGARTY BALLOON
INTRA-OPERATIVE VIEW
OTHER OPTIONS?
We've tried other alternatives and other ventriculo-peritoneal shunt materials, none with greater success than ventriculo-peritoneal shunts and 3rd ventriculostomies.
Putnam TJ: Treatment of hydrocephalus by endoscopic coagulation of the choroid plexus. N Engl J Med 210:1373‐1376, 1934.
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