Search

Background Cerebello-pontine AVMs (CPAVMs) and petrous apex dural arteriovenous fistulae (DAVFs) are rare and sometimes difficult to distinguish. We report a fatal hemorrhagic complication after coil embolization of the petrosal vein draining a trigeminal AVM misdiagnosed as a DAVF. Case presentation A 73-year-old woman with a petrous apex arteriovenous shunt with dual dural and pial arterial supply presented with posterior fossa hemorrhage. The draining petrosal vein was catheterized and coiled via the superior petrosal sinus. Two episodes of contrast extravasation occurred during coiling, but the lesion was completely occluded at the end of the procedure. The patient developed a fatal posterior fossa hemorrhage in the recovery room. Microscopic pathology revealed numerous dilated vessels within the trigeminal nerve. Conclusion CPAVMs and DAVFs with pial drainage should be distinguished pre-operatively. Occlusion of a pial vein (as opposed to a sinus) in the treatment of an arteriovenous shunt carries hemorrhagic risk if a liquid embolic agent is not used to completely occlude all pathological vessels.

The formation of an intraperitoneal pseudocyst as a complication of ventriculoperitoneal shunts is well known. However, the formation of a pseudocyst at the subcutaneous extraperitoneal abdominal space is unusual and likely secondary to the migration of the peritoneal catheter. We present a 53-year-old male who had placement of a ventriculoperitoneal shunt for hydrocephalus secondary to a vestibular schwannoma. Five months later, he presented with an enormously distended abdomen. Investigations showed the peritoneal catheter in the extraperitoneal space within a large right lower quadrant abdominal wall pseudocyst. The patient was taken to the operating theatre, and the shunt was externalised at the original abdominal incision. Approximately 3 L of cerebrospinal fluid were aspirated from the distal peritoneal catheter. After negative cultures, a new peritoneal catheter was placed intraperitoneally at the contralateral lower abdominal quadrant. The contralateral quadrant was utilised to prevent fluid accumulation into the old extraperitoneal cavity.

Abnormal communications between the systemic and pulmonary venous systems are rare but can present as a opacity on chest radiograph. A solitary vessel communicating as a fistula directly between the systemic arterial circulation and the pulmonary venous system is not widely described. These may have significant implications in the long-term cardiovascular health of an individual acting as a left to right shunt. There is no clear consensus as to the management, but surgical management and endovascular embolisation have been successfully used. We present a case where a systemic arteriaopulmonary fistula originating from the abdominal aorta and connecting to the right inferior pulmonary vein manifested as an incidental finding on a chest radiograph and was further evaluated on cross-sectional imaging in a young patient. Chest radiographs are non-specific and it is important to be aware of the less frequent but important pathologies that can be picked up on plain chest radiographs, which inturn should warrant further investigation. This is presented in conjunction with a review of the available literature along with a discussion regarding the differential diagnosis and management applicable to the general clinician.

Atrial septal defect (ASD) is the most common congenital heart disease observed in adult. Several ECG findings are considered sensitive for the diagnosis of ASD. We describe a 50 years old man who displayed Crochetage sign, incomplete right bundle branch block (IRBBB) and right ventricular strain pattern on ECG. Crochetage sign is highly specific for ASD and it correlates with shunt severity. The diagnostic specificity for ASD increases if the R waves have both Crochetage patterns and IRBBB. It is important not to confuse Crochetage signs with IRBBB abnormalities on ECG. Our patient was ultimately diagnosed with a large ASD measuring 3 cm with bidirectional shunt and concomitant pulmonary thrombosis. This illustrates that high suspicion of the ASD with the use of good-old ECG signs remains relevant in this modern era. This also reminds us that patients with Eisenmenger syndrome are at higher risk for pulmonary thrombosis.

Background The Fontan procedure, the last of a series of palliative operations for patients born with single ventricles, is associated with a significant late burden of complications. There are other strategies for patients who are suboptimal candidates for Fontan completion; however, the long-term outcomes of these different surgical options have not been clearly elucidated. We performed a systematic literature review to establish the current role of other treatment approaches besides the Fontan procedure. Methods The MEDLINE and Embase databases were systematically searched for articles describing the long-term outcomes of patients with single ventricles who have not received the Fontan procedure. Results A total of 36 articles met all inclusion criteria. There is a scarcity of contemporary data on the non-Fontan cohort. Historical studies provided a significant contribution. Conclusions Long-term survival of unoperated patients with single ventricles is possible under the rare conditions of having balanced hemodynamics. As many as half of patients may survive on only a systemic-to-pulmonary artery shunt or bidirectional cavopulmonary shunt for more than 20 years with reasonable functional status. In patients with a failing single ventricle, the bidirectional cavopulmonary shunt is an excellent bridge to heart transplantation and may provide better posttransplant survival than patients with a Fontan circulation. Currently, the Fontan procedure continues to be the best definitive palliation for patients born with single ventricle lesions. However, for those with borderline indications, other strategies should be carefully considered.

We report a clinically significant right-to-left intracardiac shunt through a patent foramen ovale, diagnosed during investigations for hypoxemia and left ventricular dilation on the late postoperative period of a HeartMate3 implantation. We discuss diagnostic pitfalls and haemodynamic influences in this scenario, as well as the possibility of successful percutaneous treatment.

Overdrainage of cerebrospinal fluid is one of the most notorious complications after ventriculoperitoneal shunt implantation. Siphon effect plays a major role in the development of overdrainage. Various overdrainage-preventing devices have been invented to counteract the siphon effect. Though some of the devices are designed to reduce the flow instead of providing antisiphoning effect, they are generally called antisiphon devices (ASDs). The basics of siphoning, the mechanisms and physical properties of currently available devices are described in this article. The clinical efficacy, shunt survival, and considerations on patient factors are also discussed. There are three kinds of ASD design, diaphragm, gravitational, and flow reducing devices. Flow reducing ASD is always open and the flow it controls is relatively stable. On the other hand, it may not provide sufficient flow in nocturnal intracranial pressure elevations. Diaphragm and gravitational devices are sensitive to the position of the patients. Diaphragm device is sensitive to the external pressure and the relative position of the device to the mastoid process. The gravitational device is sensitive to the angle between the axis of the device and the head. Many studies showed encouraging results with gravitational devices. Studies regarding diaphragm devices either showed better or similar outcomes comparing to differential pressure valves. Clinical studies regarding flow-reducing devices and head-to-head comparison between different mechanisms are warranted. This review aims to provide a useful reference for clinical practice of hydrocephalus.

Lumboperitoneal or ventriculoperitoneal shunt insertion is a standard therapy for hydrocephalus that diverts cerebrospinal fluid from the subarachnoid space into the peritoneal cavity. Gastrointestinal perforations due to this procedure occur rarely; however, accepted treatment strategies have not yet been established. Hence, the most common treatment approaches are open surgery or spontaneous closure without endoscopy. We report the case of a small intestinal perforation in a 73-year-old-woman that occurred after the insertion of a lumboperitoneal shunt. A positive cerebrospinal fluid culture and high cerebrospinal fluid white blood cell count indicated a retrograde bacterial infection, and computed tomography revealed that the peritoneal tip of the shunt catheter was located in the lumen of the gastrointestinal tract. We repaired the perforation endoscopically using an over-the-scope clip, and the patient’s recovery was uneventful. Use of an over-the-scope clip could be an effective and minimally invasive treatment for intestinal perforations caused by lumboperitoneal or ventriculoperitoneal shunt insertion.

The Blalock–Taussig–Thomas Shunt (BTTS) procedure was first introduced by Alfred Blalock, Hellen B. Taussig, and Vivien Thomas in 1944. The procedure is performed by making a connection between the subclavian artery to the pulmonary artery to augment pulmonary blood flow. BTTS is used to palliate neonates born with restrictive pulmonary blood flow disorders (cyanotic congenital heart disease). The modified BTTS (MBTTS) procedure is still seen as high risk and has quite high morbidity and mortality rates, especially in the neonatal group. Recent studies suggest a mortality of up to 15% in the single ventricle group and 3% in the biventricular group. Based on a literature search, several risk factors such as patient weight, shunt size/body weight ratio, underlying cardiac malformations, use of mechanical ventilator support, sternotomy approach and use of CPB machines have been shown to increase mortality. Current perioperative risk assessment methods and recommendations are also covered. In addition, our review article specifically discusses perioperative strategies including strategies for surgeons using the MBTTS procedure (surgical approach, determining shunt size and anastomosis techniques) and postoperative strategies (anticoagulation management and strategy to deal with undershunting/overshunting problems). Resumen: El procedimiento de derivación de Blalock-Taussig-Thomas fue introducido por primera vez por Alfred Blalock, Hellen B. Taussig y Vivien Thomas en 1944. El procedimiento se realiza al hacer una conexión entre la arteria subclavia y la arteria pulmonar para aumentar el flujo sanguíneo pulmonar. El procedimiento de derivación de Blalock-Taussig-Thomas se utiliza para paliar a los recién nacidos que nacen con trastornos restrictivos del flujo sanguíneo pulmonar (cardiopatía congénita cianótica). El procedimiento MBTTS todavía se considera un procedimiento de alto riesgo y tiene tasas de morbilidad y mortalidad bastante altas, especialmente en el grupo neonatal. Estudios recientes sugieren que hay una mortalidad de hasta el 15% en el grupo de un solo ventrículo y del 3% en el grupo de anomalías cardíacas biventrículos. Según la búsqueda bibliográfica, se ha demostrado que varios factores de riesgo, como el peso del paciente, la relación tamaño de la derivación/peso corporal, malformaciones cardíacas subyacentes, uso de asistencia respiratoria mecánica, abordaje de esternotomía y uso de máquinas de CEC, aumentan la mortalidad. También se tratan los métodos y recomendaciones actuales de evaluación de riesgos perioperatorios. Además, nuestro artículo de revisión analiza específicamente las estrategias perioperatorias, incluidas las estrategias para los cirujanos en el procedimiento MBTTS (abordaje quirúrgico, determinación del tamaño de la derivación y técnicas de anastomosis) y las estrategias postoperatorias (manejo de anticoagulación y estrategia para lidiar con problemas de sobrecapacidad/sobrecadencia).

It is crucial to have an adequate-size unobstructed branch pulmonary artery architecture to achieve an ideal cavopulmonary circulation. Branch pulmonary artery distortion, stenosis, or hypoplasia is a common problem following the stage I Norwood procedure for infants with hypoplastic left heart syndrome regardless of the shunt type. This technical review describes the surgical principle and techniques of the extensive hilum to hilum branch pulmonary artery reconstruction at the time of stage II palliation, bidirectional cavopulmonary shunt in infants with hypoplastic left heart syndrome.

Knotting or twisting of the peritoneal catheter around a bowel segment, causing bowel obstruction and necrosis, is extremely rare. Only six cases have been reported in the literature. This report described the second case of an adult patient with spontaneous knotting of the peritoneal catheter around a small-bowel segment, causing bowel obstruction and necrosis. The presentation of a knotted ventriculoperitoneal shunt around a bowel loop is stereotypical. Treatment and general recommendations have been made to help guide clinicians when encountering such cases. Evidence of small-bowel obstruction in a twisted, coiled or knotted peritoneal catheter may need surgical intervention. In the setting of progressive abdominal manifestations, knotting of the peritoneal catheter around bowel loops may cause bowel obstruction and may present with acute life-threatening manifestations. Efficient and expedite diagnosis should be made to coordinate multispecialty intervention and follow-up appropriately.

Serratia species are opportunistic, gram-negative, motile bacteria classified in the large family Enterobacteriaceae and differentiate from Klebsiella spp. with slow fermenting lactose and DNAase positive (1,2). One of the characteristics of Serratia bacteria that distinguishes them from other bacteria is to synthesize the red pigments, prodigiosins. It can cause nosocomial infections especcialy in newborns and patients in intensive care units. Serratia spp.; responsible for approximately 2% of nosocomial infections; has been reported as the responsible agent especially in respiratory tract infections, urinary tract infections and bacteremia. An outbreak of S. marcescens blood stream infection has been identified in patients receiving contaminated parenteral nutrition bags (2). It has been reported to cause S. marcescens meningitis, wound infections, arthritis and outbreaks in pediatric wards (3). In this text we aimed to present a three and a half year old girl case of acute bacterial meningitis due to Serratia spp. with ventriculo-peritoneal shunt.

Background Mechanical obstruction of ventriculoperitoneal shunt (VPS) during the first year after shunt implantation is a common complication and is widely described in the literature. In this paper, we evaluated the suitability of the shuntography for the diagnosis of mechanical complications of the VPS in patients with idiopathic normal pressure hydrocephalus (iNPH). Methods We retrospectively identified 49 patients with pathologic shuntography over of a period of 20 years in our hospital. The percentage of procedure-associated complications was determined. Results Ninety-eight percent (n = 48) of the patients who underwent shuntography showed clinical and radiographic signs of underdrainage prior to examination. Shuntography revealed mechanical complications of the VP shunt in 37% (n = 18) as a cause of clinical deterioration and following revision operation. During shuntography, mechanical obstruction was discovered in 78% (n = 14) and disconnection of shunt components in 22% (n = 4). In the obstruction group, in 50% (n = 7) the closure was detected in the ventricular catheter, in 29% (n = 4) in the distal catheter of the VPS, and in 21% (n = 3) in both sides of the VPS. In the case of an inconspicuous shuntography (63%, n = 31), the patients received symptomatic therapy (32%, n = 10) or re-adjustment of the valve setting (68%, n = 21). Fifty-seven percent of the patients who underwent surgical treatment improved clinically by at least one point according to the Kiefer score. Conclusion Shuntography can produce valuable clinical information uncovering mechanic complications after implantation VPS in patients with idiopathic normal-pressure hydrocephalus. Patients with mechanical complications of their VPS needed revision surgery and showed clinical benefit after treatment.

BACKGROUND Hepatic encephalopathy (HE) is a frequent and debilitating complication of chronic liver disease. Recurrent HE is strongly linked with spontaneous portosystemic shunts (SPSSs). Intrahepatic arterioportal fistulas (IAPFs) occur rarely but pose a major clinical challenge and may lead to or worsen portal hypertension. Herein, we present a rare case of recurrent HE secondary to a SPSS combined with an IAPF. CASE SUMMARY A 63-year-old female with primary biliary cirrhosis presented with recurrent disturbance of consciousness for 4 mo. SPSS communicating the superior mesenteric vein with the inferior vena cava and IAPF linking the intrahepatic artery with the portal vein were found on contrast-enhanced abdominal computed tomography. The patient did not respond well to medical treatment. Therefore, simultaneous embolization of SPSS and IAPF was scheduled. After embolization, the symptoms of HE showed obvious resolution. CONCLUSION The presence of liver vascular disorders should not be neglected in patients with chronic liver disease, and interventional therapy is a reasonable choice in such patients.

Background Systemic to pulmonary shunt (Shunt) is offered for children with duct dependent pulmonary circulation to augment pulmonary flow. Recently patent ductus arteriosus (PDA) stent (Stent) is widely used as an alternative method. We aimed to compare post intervention outcomes in children underwent either procedure. Methods Infants under 3 months who had an initial palliation by Shunt or Stent were retrospectively reviewed between 2008 and 2016, then followed till the second intervention or 1 year whichever earlier. Results 187 patients (110 Shunt and 77 Stent) were included. Initial weight and pulmonary artery (PA) branches size were similar between the groups. Shunt patients had more shock preoperatively and required more emergency intervention. Stent group showed less ICU stay 4 (1–8) vs 13 (7–23) days, p < 0.0001 and less positive pressure ventilation days 1 (0–2) vs 5.5 (3–11), p < 0.0001. However, Stent group had more symptomatic arterial and deep venous thromboses. In Stent patients the branch PAs growth was better and more homogeneous. At follow-up, no difference between groups regarding cumulative readmission days to hospital, hemoglobin levels and the weight percentile for age. Mortality was not different with a tendency to be higher in the Shunt group (13%) compared to the Stent group (5%), p 0.1. Conclusions The implantation of PDA stent in patients with duct dependent pulmonary circulation results in a smoother ICU course and a shorter hospital stay, with higher risk of vascular injury. Shunt and Stent procedures have a good outcome for PA growth, somatic growth and survival.

Variceal bleeding is a serious complication of cirrhosis and portal hypertension. Despite the improvement in management of acute variceal bleed (AVB), it still carries significant mortality. Portal pressure is the main driver of variceal bleeding and also a main predictor of decompensation. Reduction in portal pressure has been the mainstay of management of variceal bleeding. Transjugular intrahepatic porto-systemic stent shunt (TIPSS) is a very effective modality in reducing the portal hypertension and thereby, controlling portal hypertensive bleeding. However, its use in refractory bleeding (rescue/salvage TIPSS) is still associated with high mortality. “Early” use of TIPSS as a “pre-emptive strategy” in patients with AVB at high risk of failure of treatment has shown to be superior to standard treatment in several studies. While patients with Child C cirrhosis (up to 13 points) clearly benefit from early-TIPSS strategy, it’s role in less severe liver disease (Child B) and more severe disease (Child C > 13 points) remains less clear. Moreover, standard of care has improved in the last decade leading to improved 1-year survival in high-risk patients with AVB as compared to earlier “early” TIPSS studies. Lastly in the real world, only a minority of patients with AVB fulfil the stringent criteria for early TIPSS. Therefore, there is unmet need to explore role of early TIPSS in management of AVB in well-designed prospective studies. In this review, we have appraised the role of early TIPSS, patient selection and discussed future directions in the management of patients with AVB.

After revascularization surgery for patients with moyamoya disease (MMD), local and global hemodynamic changes occur intraoperatively and in the early postoperative period. Local cerebral hyperperfusion and watershed shift ischemia are well-known perioperative pathologies after revascularization for MMD, but early venous filling phenomenon is markedly rare. We report the case of a 19-year-old woman with hemorrhagic-onset MMD who presented with grand mal seizure and subarachnoid hemorrhage. She underwent superficial temporal artery (STA)–middle cerebral artery (MCA) anastomosis combined with indirect pial synangiosis on the affected hemisphere. Intraoperatively, notable early arterial blood filling in the fine cortical vein was observed around the site of anastomosis right after the STA–MCA anastomosis under the surgical microscope and fluorescence indocyanine green video angiography. Recovery of consciousness after general anesthesia was normal, although she exhibited a focal seizure 1 hour later. Postoperative magnetic resonance imaging was not remarkable, and cerebral hemodynamics significantly improved in the acute stage after surgical revascularization. Considering the intrinsic vulnerability of the microvascular anatomy of MMD, the present case is notable because early venous filling was observed intraoperatively. This phenomenon suggests the existence of a potential arteriovenous shunt as an underlying pathology of MMD, but its implications in the early postoperative course should be further verified in a larger number of MMD patients undergoing surgical revascularization.

Objective. To evaluate the results of treatment of prehepatic portal hypertension (PPH) in children by method of side-to-side splenorenal bypass. Methods. A retrospective, monocentric analysis of 114 patients with prehepatic portal hypertension was carried out in the period from 2000 to 2018. The age of the patients was from 6 months up to 18 years, the average age 10,1±3,8 years (M±σ). All patients underwent side-to-side splenorenal shunt. In the postoperative period, on the 7th day, ultrasound examination of the abdominal organs with Doppler sonography (US) was performed to assess the volume of the spleen, the rate of portohepatic perfusion, the rate of blood flow along the side-to-side splenorenal shunt, as well as to assess its diameter. Control US was performed after the 1st, 3rd, 6th, 12th months; to assess the regression of esophageal and gastric varicose veins, the control esophagogastroduodenoscopy (EYD) was performed after 3rd , 6th, 12th months and then once a year. Subsequently, the control examination of the patients was carried out once a year. The follow-up was 2-18 years. Results. Out of 114 patients who underwent side - to - side splenorenal shunt, 5 (4,4%) patients had recurrent bleeding from the esophageal variceal vein at the follow-up period (2-18 years). One patient had intra-abdominal arrosive bleeding from side-to-side splenorenal shunt provoked by severe postoperative pancreatitis. The average diameter of the shunt was 12±1.9 mm. The spleen volume decreased by 39.7±10.3%. Portohepatic perfusion reduced by 39% in comparison with the indicators before surgery. The blood flow rate along the side -to-side splenorenal shunt was 2403±557.3 ml/min. in 95,4% of patients the regression of variceal vein was noted. Hypersplenism syndrome was arrested in 73.6% of children. Conclusion. Side -to- side splenorenal shunt is considered to be an effective method of portal decompression with the effectiveness inpreventingboth esophageal and gastricvariceal veins bleeding in 95,4% of patients. What this paper adds The results of treatment of the prehepatic portal hypertension by method of side-to-side splenorenal shunt have been firstly analyzed, and the effect of this variant of portosystemic shunt on portohepatic perfusion has been assessed. It has been established that this option of shunt is effective for the portal system decompression and occupies an intermediate position between selective and total variant of portosystemic shunt.

Childhood priapism is a rare entity and there is currently no consensus regarding its contemporary management. The use of perioperative anticoagulation and open distal corpora-glandular shunt procedure in the management of childhood priapism has not been reported in the literature. We present a stuttering case of a 13-year-old boy who presented with idiopathic ischaemic priapism lasting 13 h in duration, which recurred despite corporal aspiration and alpha-adrenergic agonist injections, percutaneous distal shunt surgery, and revision of percutaneous distal shunt surgery. He was eventually successfully managed with perioperative subcutaneous enoxaparin, oral aspirin and clopidogrel in conjunction with an Al-Ghorab shunt, which led to sustained detumescence but with spontaneous morning erections. In paediatric patients with sustained childhood priaprism failing stepwise treatments, an Al-Ghorab shunt with perioperative anticoagulation is a viable option.

Ventricular shunting is a well-recognised and commonly practiced method of reducing increased intracranial pressure in patients with neurologic pathology. There are possible complications related to shunt implantation, where the rarest is intracardiac migration of the distal shunt catheter. We present a case where the distal catheter migrated into the right ventricle, causing extrasystoles and was complicated with acute right ventricle failure during the endovascular shunt evacuation procedure.

Psychrobacter piechaudii is a recently described species of Gram-negative bacteria in the Moraxellaceae family. No cases of human infection due to this species have been described before. We report the case of an ex-premature infant girl with hydrocephalus secondary to intraventricular haemorrhage who underwent multiple cerebrospinal fluid (CSF) shunt operations. She ultimately developed Psychrobacter piechaudii meningitis, presenting as ventriculoperitoneal shunt dysfunction and wound leak, which necessitated removal of the shunt, a period of external ventricular drainage and antibiotics. We found this organism to be sensitive to intravenous ceftazidime (50 mg/kg) and ciprofloxacin, and a 7-10 day treatment course prior to shunt re-insertion (and 3 week total course) was sufficient. The patient is well post-operatively. To the best of our knowledge, this is the first reported case of Psychrobacter piechaudii infection in a human.

Hepatic encephalopathy caused by a large portosystemic shunt (PSS) can be treated by endovascular embolization of the shunt. The PSS diameter can be >20 mm; it occasionally poses technical difficulties. Here, a 72-year-old woman with liver cirrhosis, hyperammonemia, and large spleno-renal shunt underwent shunt embolization using an Amplatzer vascular plug 2 (AVP2) and metallic coils. The preloading coil in plug method (p-CIP), which facilitated embolization inside the AVP2 without cannulation from outside, was employed to overcome technical difficulties. We propose the use of p-CIP with an AVP2 as a tool for treatment of hepatic encephalopathy with PSS.

Background and Objectives: To assess the outcome of Endoscopic Third Ventriculostomy (ETV) versus Ventriculoperitoneal Shunt (VPS) in Obstructive Hydrocephalus in terms of infections, foreign bodies, cost-effectiveness, and length of hospital stay. Materials and Methods: It was a Randomized Controlled Trial study, in which 30 patients with Obstructive Hydrocephalus were divided into two groups one was treated with (ETV) and the other was treated with VP Shunt and the patients were followed up for 1 year. Results: Patients were divided into 2 groups, 15 were treated with ETV, and 15 were treated with VP Shunt. Length of stay for VP shunt was 7 ± 0.85 days and for ETV mean stay was 2.93 ± 1.1 days. The complication was observed in 4 (26.7%) treated with VP Shunt and in 3 (20%) patients with Endoscopic Third Ventriculostomy. In ETV, 3 (20%) patients had recurrence whereas in VP shunt in 1 (6.67%) had an infection and in 3 (20%) patients had recurrence (upper-end blockage) and the overall success rate was 76% in both the procedures and in VP Shunt 73.3% and ETV 80%. Overall there were no complications found in 23 (76.6%) patients, in 3 (10%) patient’s complications were found at 1st month, in 3 (10%) complications were observed at 3rd month, and in 1(3.3%) complication was recorded at 6th month. Conclusion: ETV was found better in terms of length of hospital stay, cost-effectiveness as well as minimal complication rate as compared to VP shunt.

The authors report the clinical case of secondary Takotsubo syndrome developed after transcatheter aortic valve replacement that was performed in compassionate manner in female patient with combination of congenital ventricular septal defect and acquired severe aortic stenosis. In the teams view, Takotsubo syndrome was triggered with profound changes of intracardial hemodynamics subsequent to iatrogenic impairment of preexisting interventricular shunt.Авторы приводят клиническое наблюдение вторичного синдрома Такоцубо после транскатетерной имплантации аортального клапана, предпринятой в качестве паллиативного вмешательства у пациентки с сочетанием врожденного дефекта межжелудочковой перегородки и приобретенного клапанного аортального стеноза. По мнению авторов, триггером синдрома Такоцубо в данном случае послужило критическое изменение внутрисердечной гемодинамики при ятрогенном воздействии на степень межжелудочкового шунтирования крови.

Background Aneurysm of vein of Galen is a rare congenital arteriovenous malformation. Clinical manifestations depend on the age of discovery. Endovascular embolization is currently the treatment of choice. This technique is not always available in developing countries. We report 3 cases treated symptomatically by endoscopic third ventriculostomy and ventriculoperitoneal shunt. Cases presentation Three patients, 7 months, 15 years, and 26 years old, received in a table of acute intracranial hypertension, associated for the first one with convulsions and for the second one with moderate heart failure. Bain CT scan revealed triventricular hydrocephalus secondary to sacciform dilatation of the Galen’s vein in all three patients, requiring symptomatic treatment by endoscopic third ventriculostomy for the first patient and ventriculoperitoneal shunt for the other two in the absence of an adequate clinical platform for endovascular embolization. The evolution was favorable at 1 year’s follow-up. Conclusion Galen’s vein aneurysm is a rare vascular malformation. It mainly affects newborns and small children but can be discovered in adulthood. Endovascular embolization is its treatment of choice. This technique is not always available in some countries, which makes it necessary to resort to symptomatic treatment by ventricular shunt.

Ventriculoperitoneal (VP) Shunt is a commonly performed surgical procedure and offers a good result in the treatment of hydrocephalus. In general, 25% of the complication rate of this surgical procedure is abdominal complications. Anal extrusion of a peritoneal catheter is a rare complication ranging from 0.1 to 0.7% of all shunt surgeries. This study presents a rare case of anal extrusion of ventriculoperitoneal shunt in a 1-year-old female child who was asymptomatic. The physical examination revealed swelling and redness along the shunt tract on the retro auricular region, soft abdomen, and no catheter was observed in the anal. This study found several contributing factors affecting the complications in the anal extrusion of a peritoneal catheter, that are thin bowel wall in children and sharp tip and stiff end of VP shunt. The shunt should be disconnected from the abdominal wall, and the lower end should be removed through the rectum by colonoscopy or sigmoidoscopy/proctoscopy or by applying gentle traction on the protruding tube. This study concludes that due to potentially life-threatening consequences and case rarity, thorough anamnesis, physical examination, and objective investigation are needed to determine the appropriate management for anal extrusion of ventriculoperitoneal shunt.Â

Background The ventriculoperitoneal shunt (VPS) procedure is still the most used technique for management of hydrocephalus. This article reports a case of hepatic cerebrospinal fluid (CSF) pseudocyst as a rare, but important, complication of the VPS insertion. Case Description An 18-year-old male presented to the hospital complaining of temporal headache and visual turbidity for approximately 3 months with a history of VPS insertion for treatment of hydrocephalus and revision of the valve in adolescence. The diagnosis was based on abdominal imaging, demonstrating an extra-axial hepatic CSF pseudocyst free from infection. Following the diagnosis, the management of the case consisted in the removal and repositioning of the catheter on the opposite site of the peritoneum. Conclusion The hepatic CSF pseudocyst is an infrequent complication of VPS procedure, but it needs to be considered when performing the first evaluation of the patient. Several techniques are considered efficient for the management of this condition, the choice must be made based on the variables of each individual case.

Hydrocephalus is a neurological disorder caused by excessive accumulation of the cerebrospinal fluid (CSF) in the ventricles of the brain. It can be treated by diverting the extra fluid to different parts of the body using a device called a shunt. This paper reviews different shunt devices that are used for this purpose.Shunts have high failure rates either due to infection or mechanical failure, therefore there is still ongoing work to address these two main handicaps. They require additional devices for performance assessment. Here, the paper also reviews different approaches for assessing shunt limitations. Moreover, future prospects are also discussed.This study shows that shunt devices still remain an important treatment option for hydrocephalus. However, further efforts are required to design more advanced shunts, to eliminate high failure rates in clinical use. Sophisticated sensor systems that can accurately detect and regulate changes in CSF drainage to optimize drainage for individual needs. Moreover, shunt infection problem is still present despite recent improvements such as antibiotic impregnated catheters.

Vascular injuries to the upper or lower limb in the context of significant soft tissue loss, fractures, or other life-threatening injuries are associated with a high amputation rate. Complex extremity vascular injuries in which acute arterial insufficiency combined with severe or prolonged shocks are unacceptable because warm, warm, skeletal muscle time is often exceeded before adequate revascularization, and are associated with extended ischemia periods or fractures or soft tissue wounds. Revascularizing the limb is essential for the success of the limb rescue. Selective intravascular temporary shunting hence allows better overall care of the patient and can therefore be predicted to increase both limb rescue and patient survival rates. The aim of this article was to review and summarize results of previous literature regarding effectiveness on intravascular shunting as management of limb trauma as well as reviewing its potential complications.

BACKGROUND: The placement of a pulmonary-to-systemic arterial shunt in children with severe pulmonary hypertension (PH) has been demonstrated, in relatively small studies, to be an effective palliation for their disease.OBJECTIVES: The aim of this study was to expand upon these earlier findings using an international registry for children with PH who have undergone a shunt procedure.METHODS: Retrospective data were obtained from 110 children with PH who underwent a shunt procedure collected from 13 institutions in Europe and the United States.RESULTS: Seventeen children died in-hospital postprocedure (15%). Of the 93 children successfully discharged home, 18 subsequently died or underwent lung transplantation (20%); the mean follow-up was 3.1 years (range: 25 days to 17 years). The overall 1- and 5-year freedom from death or transplant rates were 77% and 58%, respectively, and 92% and 68% for those discharged home, respectively. Children discharged home had significantly improved World Health Organization functional class (P < 0.001), 6-minute walk distances (P = 0.047) and lower brain natriuretic peptide levels (P < 0.001). Postprocedure, 59% of children were weaned completely from their prostacyclin infusion (P < 0.001). Preprocedural risk factors for dying in-hospital postprocedure included intensive care unit admission (hazard ratio [HR]: 3.2; P = 0.02), mechanical ventilation (HR: 8.3; P < 0.001) and extracorporeal membrane oxygenation (HR: 10.7; P < 0.001).CONCLUSIONS: A pulmonary-to-systemic arterial shunt can provide a child with severe PH significant clinical improvement that is both durable and potentially free from continuous prostacyclin infusion. Five-year survival is comparable to children undergoing lung transplantation for PH. Children with severely decompensated disease requiring aggressive intensive care are not good candidates for the shunt procedure.

Resonant structural vibrations are a common source of disruptive noise, and suppressing these vibrations is often the most direct way to reduce the noise levels. Elastic metamaterials (EMMs) consist of distributed resonant substructures, at a scale which is small compared to the wavelength of vibration. This allows these materials to be used in applications where space is limited, and more traditional vibration suppression techniques would be impractical. Tuned resonators can be designed through selection of geometry or material properties, but an alternative approach, which requires significantly less prototyping, is through the use of shunted electrodynamic inertial actuators. In this paper, a novel electrodynamic metamaterial (EDMM) is proposed consisting of an array of mass-produced inertial actuators, each connected to a tuned shunt impedance. It is considered impractical to measure the dynamic and electrical parameters of a large number of actuators, and so the effect of uncertainties in the actuators is investigated on both the performance and the stability of the EDMM.

A 54-year-old man suddenly developed impaired consciousness and left hemiplegia due to a right thalamic hematoma. Emergent ventricular drainage for acute hydrocephalus improved the level of consciousness, but macrosquare-wave jerks (MSWJ) consisting of a right-ward intrusive saccade and corrective saccade appeared. The MSWJ disappeared on day 2 when follow-up CT revealed improvement of hydrocephalus. However, on day 36, after ventricular drainage was clamped, the MSWJ reappeared. After ventriculoperitoneal shunt, MSWJ again subsided. In this patient, hydrocephalus may have stretched the superior colliculus, thereby decreasing activity of the fixation neurons and then omnipause neurons, and eventually resulting in the reversible MSWJ.

BACKGROUND: One of the most common causes of extrahepatic portal hypertension in children is portal vein thrombosis. The causes of this disease are different and, in most cases, remain unrecognized. Along with this, the mesoportal shunt (Rex shunt) proved itself and today is considered the gold standard to treat extrahepatic portal hypertension in children. The restoration of hepatopetal blood flow eliminates gastroesophageal bleeding, splenomegaly, hypersplenism, and many other complications. For the results of mesoportal shunt to be successful, several conditions must be met, one of which is the patency of the umbilical portion of the left portal vein. Despite the importance of preoperative diagnostics of the patency of this area, the most optimal instrumental research method has not yet been found. AIM: This literature review aims to highlight the main issues of extrahepatic portal hypertension etiopathogenesis, surgical treatment methods, and the most effective preoperative diagnostic methods to assess the patency of the left portal vein. RESULTS: The authors analyzed the sources of domestic and foreign literature on the etiology, pathogenesis of HSV in children, and laboratory and instrumental diagnostic methods to assess the patency of the PVI to plan the mesoportal shunting operation. CONCLUSIONS: Extrahepatic portal hypertension is a polyetiological disease with a possible hereditary predisposition to a thrombotic process under the influence of various triggers. The most common causes of portal vein thrombosis are omphalitis and umbilical vein catheterization in the neonatal period. Unfortunately, to date, none of the existing instrumental diagnostic methods can reliably answer the question about left portal vein patency. Due to the small number of works, the lack of a unified view on the problem of preoperative diagnosis of patients with extrahepatic portal hypertension, we could not reliably determine the specificity, sensitivity, and accuracy of each instrumental method. Therefore, we could not identify the gold standard method. Nevertheless, with further improvement of the methods for preoperative assessment of the left portal vein patency, surgeons will be more likely to predict the successful outcome of mesoportal shunting, which will generally affect the surgical treatment quality of extrahepatic portal hypertension in children.

BACKGROUND: Myelomeningocele (MMC) is one of the most common developmental anomalies of the CNS. Many of these patients develop hydrocephalus (HCP). The rate of cerebrospinal fluid diversion in these patients varies significantly in literature, from 52% to 92%. MMC repair conventionally occurs in the post-natal period. With the technological advances in surgical practice and fetal surgeries, intra uterine MMC repair IUMR is adopted in some centers. Cerebrospinal fluid shunting has numerous complications, most notably shunt failure and shunt infection. Studies have suggested that patients with greater numbers of shunt revisions have poorer performance on neuropsychological testing. There is also good evidence to suggest that the IQs of patients with MMC who do not undergo shunt placement are higher than that of their shunt treated counterparts. AIM: In this study, we are trying to identify strong clinical and radiological predictors for the need of ventriculoperitoneal (VP) shunt insertion in patients with MMC who underwent surgical repair and closure of the defect initially. This will decrease the overall rate of shunt placement in this group of patients through applying a strict policy adopting only shunt insertion for the desperately needing patient. METHODS: Prospective clinical study conducted on 96 patients with MMC presented to Aboul Reish Pediatric Specialized Hospital, Cairo University. After confirming the diagnosis through clinical and radiological aids, patients are carefully examined, if HCP is evident clinically and radiologically a shunt is inserted together with MMC repair at the same session after excluding sepsis or cerebrospinal fluid (CSF) infection, (GROUP A). If there are no signs of increased ICP, MMC repair shall be done alone (GROUP B). Those patients shall be monitored carefully postoperatively and after discharge and shall be followed up regularly to early detect and promptly manage latent HCP. Multiple clinical and radiological indices were used throughout the follow-up period and statistical significance of each was measured. RESULTS: Shunt placement was required in 45 (46.88%) of the 96 patients. Eighteen patients (18.75%) needed the shunt as soon as they presented to us (GROUP A), because they were having clinically active HCP. Twenty-seven (28.13%) patients were operated on by MMC repair initially without shunt placement because they did not have signs of increased ICP at the time of presentation. Yet, they developed latent HCP requiring shunt placement during the follow-up period (GROUP B2). Fifty-one patients of the study population (53.13%) underwent surgical repair of the MMC without the need of further VP insertion and they were followed up for 6 months period after the repair without developing latent HCP (GROUP B1). Patients of GROUP B were the study population susceptible for the development of latent HCP. Out of 78 patients in GROUP B, only 27 patients (34.62%) needed a VP shunt. CONCLUSION: In our study, we found that the rate of shunt insertion in patients with MMC is lower than the previously reported rate in the literature. A more thorough evaluation of the patient’s post-operative need for a shunt is mandatory. We suggest that we could accept postoperative (after MMC repair) ventriculomegaly provided it does not mean any deterioration in the patient’s clinical or developmental state. We assume that reduction of shunt insertion rate will eventually reduce what has previously been an enormous burden for a significant proportion of children with MMC.

Patent foramen ovale might cause cryptogenic strokes, including retinal artery occlusion. Herein, we describe a previously healthy young man who presented with central retinal artery occlusion in the setting of patent foramen ovale and explore the need for transesophageal echocardiogram for its diagnosis. Cardiovascular workup and neuroimaging were unremarkable. Transthoracic echocardiogram bubble study revealed a right to left atrial shunt and subsequent transesophageal echocardiogram disclosed patent foramen ovale. This congenital cardiac anomaly was the likely conduit for a thrombo-embolic central retinal artery occlusion. We identified seven patients with patent foramen ovale associated with central retinal artery occlusion in the literature. Transthoracic echocardiogram was diagnostic in only one patient (14.3%), whereas transesophageal echocardiogram was required to reveal patent foramen ovale in the remaining six (85.7%). Our case and the previous reports support the link between central retinal artery occlusion and patent foramen ovale. Therefore, providers should consider the more sensitive transesophageal echocardiogram during the initial evaluation of young patients without immediately identifiable causes of retinal artery occlusion.

Background Right ventricle-to-pulmonary artery (RV-PA) shunt as a part of the Norwood procedure underwent many modifications. We present our experience with a commercially available polytetrafluoroethylene vascular graft with cobra-head cuff as an RV-PA shunt. Methods A consecutive series of 52 children with hypoplastic left heart syndrome (median age 8 [range, 2-68] days, median weight 3200 [range, 2060-4400] g) underwent the Norwood procedure with a cobra-head cuffed RV-PA shunt (6 mm). The cuffed end was used for the central PA reconstruction. A retrospective analysis of clinical results, PAs development, and shunt-related complications, interventions, and technique of Glenn operation was performed. The study endpoint was Glenn operation with shunt removal or interstage death. Results The hospital and late interstage mortality was 3.8% (n = 2 of 52) and 4% (n = 2 of 50), respectively, and was not shunt-related. During mean follow of 3.7 ± 2.5 years, 48 (92.3%) children underwent Glenn operation at a median age of 6 (range, 2.6-9.1) months. Angiography before the second stage revealed satisfactory branch PAs development (maximum and minimum McGoon ratio of 1.95 ± 0.36 and 1.38 ± 0.38, respectively). The mean maximal diameter of the left PA was smaller than that of the right PA (7.13 ± 2.1 mm vs 8.42 ± 2.2 mm; P = .017), without differences in mean minimal diameter. Two infants required stent implantation in proximal shunt end and 1 required urgent Glenn operation because distal shunt thrombosis. During Glenn operation, 11 (22.9%) children required patch reconstruction of central PAs. Conclusions The cobra-head cuffed graft allowed easy and reproducible reconstruction of the central PA during the Norwood procedure. Using this technique, the development of PAs is satisfactory, the rate of shunt-related complications and interventions is low, and the second stage can be performed without patch material.

Background The authors of this study aim to summarize their experience with lateral ventriculosinus shunt in the treatment of hydrocephalus patients and assess its clinical value. Methods Ventriculoperitoneal shunt was performed but failed due to obstruction and infection of the shunt. Lateral ventriculosinus shunt was inserted in 19 hydrocephalus patients by a Medtronic programmable shunt valve. All 19 patients suffered from either an obstruction or infection after ventriculoperitoneal shunting, while 11 cases had a peritoneal obstruction, 8 cases had an intracranial infection, and 1 case had an intra-abdominal infection. Among the 19 cases, there were 2 cases with obstructive hydrocephalus and 17 cases with communicating hydrocephalus. Results All clinical symptoms of 9 patients disappeared completely, while for 8 patients, noticeable improvement was accomplished, and only 2 patients showed no improvement. All 19 cases were followed up for 6 to 60 months. During the follow-up period, in 17 patients the shunt remained effective, while 2 cases underwent removal of the shunt due to low preoperative intracranial pressure and no significant changes in postoperative symptoms and ventricular size. During follow-up there was no thrombosis in the sagittal sinus, and no infection, over drainage, intracranial hemorrhage, or subdural effusion occurred. Conclusions We demonstrate that lateral ventriculosinus shunt is a reliable option for failed ventriculoperitoneal shunt hydrocephalus patients. Nevertheless, the effectiveness and possible complications of this method need further confirmation by observation in a study with a larger cohort.

Background: Shunt Infection is a common complication of shunt insertion in children which can lead to bad neuro-developmental conditions and impose a considerable economic burden for the health care system. So, identifying predictive factors of shunt infection could help us in the proper improvement of this deteriorating condition. Methods: In this study, related risk factors of 68 patients with history of shunt infection and 80 matched controls without any history of shunt infection, who were all operated in a single referral hospital were assessed. Three machine learning (ML)-based measures including sparsity, correlation, and redundancy along with specialist’s score were applied to select the most important predictive risk factors for shunt infection. ML was determined by summation of sparsity, correlation and redundancy measures, and the final total score was considered as normalization (ML-based score + specialist score). Results: According to the total score, prematurity, first ventriculoperitoneal shunting (VPS) age, intraventricular hemorrhage (IVH), myelomeningocele (MMC) and low birth weight had higher weights as shunt infection risk factors. icterus, trauma, co-infection and tumor had the lowest weights and history of meningitis and number of shunt revisions were defined as intermediate risk factors. Conclusion: The "ML-based clinical adjusted" method may be used as a complementary tool to help neurosurgeons in better patient selection and more accurate follow-up of children with higher risk of shunt infection.

Проблема профилактики и диагностики стеноза - окклюзирования шунтов после аорто - коронарного шунтирования в отдаленном периоде остается нерешенной. Наиболее часто закрываются шунты в течение первого года, возникновение окклюзии венозных шунтов в течение первого года после операции наблюдаются у 25-30% больных, в дальнейшем в течении 5-7 лет частота окклюзии составляет около 2% в год, после этого срока 5% в год. Артериальные шунты остаются проходимы до 98%, и в основном причиной их дисфункции является прогрессирование атеросклеротического процесса и технические погрешности. Основными причинами которые могут привести к нарушению функции шунта в отдаленном периоде считают [1, 2, 4, 6, 8] следующие: 1-техническое (повреждение эндотелиального слоя и стенки аутовенозного трансплантата при его взятии (ретроспективный анализ), чрезмерная длина и перегиб шунта (на шунтографии), натяжение шунта из-за недостаточной его длины, неправильный выбор места наложения дистального анастомоза) [11,12,13]. 2- анатомические факторы[3, 5, 7] . 3 - общие факторы (низкая объемная скорость кровотока по шунту, нестабильность общей гемодинамики, массивные сращения в полости перикарда, гиперкоагуляция, гнойный медиастинит, длительное лихорадочное состояние и неадекватный прием антикоагулянтов. 4 - прогрессирование атеросклероза [9]. 5- использование венозных трансплантантов как одна из важных причин стеноза - окклюзии шунта [10]. The Problem of stenosis prevention and diagnostics - occlusion of shunts after aorto-coronary bypass in long term remains unaddressed. Typically, shunts are closed within the first year, emergence of phleboid shunts occlusion within the first year after surgical intervention is observed in 25-30% of patients, and further frequency of occlusion within 5-7 years is about 2% per year, 5% per year after this term. Arterial shunts is passable up to 98%, and mainly the reason for their dysfunction is the atherosclerotic process progression and technical faults. The main reasons which can results in shunt dysfunction in long term are the following [1, 2, 4, 6, 8]: 1-technical (damage of endothelial layer and paries of autovenous transplant during its drawing (retrospective analysis), excess length and shunt bend (at the shuntography), shunt tension because of its insufficient length, improper location of distal anastomosis application) [11,12,13]. 2- anatomical factors [3, 5, 7] . 3 - general factors (low volumetric blood flow along the shunt, instability of general hemodynamics, dense adhesion in pericardial cavity, hypercoagulability, purulent mediastinitis, prolonged febrile state and inadequate intake of anticoagulants. 4 - atherosclerosis prgression [9]. 5- using venous transplants as one of the important reasons of stenosis - shunt occlusion [10].

Objective Shunt treatment for hydrocephalus in children should aim for sustainable flexibility in regard to optional, perspective pressure level adjustment during advancing physical and mental development. Gravitation-assisted shunt valves are designed to prevent hydrostatic over-drainage frequently observed in the long course of shunt-treated hydrocephalus. We prospectively studied and analyzed the implication, safety, and feasibility for an adjustable gravitational unit combined with a fixed differential-pressure (DP) valve for neonates and infants primary shunted within the first 12 months of life. Methods Clinical course of hydrocephalic neonates and infants who received initial VP-shunt insertion in the early post-natal phase were monitored prospectively on the basis of our digital institutional Hydrocephalus & Shunt Registry. All patients were equipped with a fixed DP valve combined with a programmable gravitational unit activated in upright body position. Patients with a minimum shunt follow-up of 24 months were considered for further statistical analysis regarding hydrocephalus etiology, surgical setting, pre- and post-operative ventricular enlargement, head circumference, valve pressure setting, implication for the adjustment option of the gravitational unit, type and number of shunt complications, and revision-free shunt and valve survival. Results Seventy-eight pediatric patients received primary VP-shunt insertion at a mean age of 10 weeks with age gestationally corrected for preterm neonates. Hydrocephalus was related to perinatal IVH (64%), CNS malformation (11%), spina bifida (9%), congenital aqueductal stenosis (9%), and idiopathic (4%) or post-infectious etiology (3%). Fifty-two patients (70%) presented with history of prematurity (gestational age 23–36 weeks). Regular follow-up carried out for a mean period of 63 months demonstrated that ventricular enlargement decreased significantly after applied treatment and excessive head growth could be counteracted effectively. At least one pressure level adjustment was performed in 31% of all patients after 12 months, in 42% after 24 months, and in 64% at the time of last clinical follow-up since initial shunt insertion. Pressure level adjustments were successful in cases of clinical or radiographic signs of under- or over-drainage for individual patients of various ages during entire clinical course. Mean pressure setting for upright position was 24.1 cm H2O at the time of initial shunt insertion and increased to 26.4 cmH2O at the time of last clinical follow-up. Revision-free shunt-survival rates after 12 and 24 months were 79% and 70% and valve-survival rates 91% and 90%, respectively. Conclusion The combination of a fixed DP valve with an adjustable gravitational unit utilized as first-line shunt regimen was feasible and safe in a highly vulnerable subgroup of hydrocephalic infants. The adjustment option for the gravitational unit showed frequent and increasing implication over time and was beneficial even during the very early developmental stage of limited autonomous mobility. To our knowledge this is the first ever reported long-term investigation of an age-consistent pediatric patient collective primary shunted with an adjustable gravitational valve system.

A 42-year-old woman visited our hospital due to syncope. Contrast-enhanced CT revealed portosystemic shunt, portal vein hypoplasia, and multiple liver nodules. The histological examination of a liver biopsy specimen exhibited portal vein hypoplasia and revealed that the liver tumor was positive for glutamine synthetase. The patient was therefore diagnosed with congenital extrahepatic portosystemic shunt type II, and with focal nodular hyperplasia (FNH)-like nodules. She had the complication of severe portopulmonary hypertension and underwent complete shunt closure by balloon-occluded retrograde transvenous obliteration (B-RTO). The intrahepatic portal vein was well developed at 1 year after B-RTO, and multiple liver nodules completely regressed. Her pulmonary hypertension also improved.

Ventriculoperitoneal shunting (VPS) is a common procedure involved in the management of hydrocephalus. VP shunt has many inherent complications including obstruction, infection, breakage, and migration of the shunt. The incidence of scrotal shunt migration is around 14% VPS migration into the scrotum manifests as reducible trans-illuminant scrotal swelling, which is more like hydrocele. Mostly migration occurs into the right hemi-scrotum within the first 6 months of performing a ventriculoperitoneal shunt. Bilateral herniotomy with repositioning of the distal shunt catheter is the treatment of choice.

Background: Shunting procedure still represents the backbone for the treatment of hydrocephalus. To have an exposed shunt is a nightmare every neurosurgeon wish to avoid encountering in his career. However pediatric patients with hydrocephalus are a predisposed category for this com-plication, possessing friable and delicate skin, larger head size with added skin stresses on pressure points, occasionally malnourished or premature, all of which can lead to or accel-erate the process. Objective: The aim of this study is to address the technique of the pericranial flap and the sub-pericranial shunt valve placement in the pediatric hydrocephalic patients predisposed to shunt exposure due to friable skin in an attempt to overcome this serious complication. Methods: This study was done prospectively in the Cairo University hospitals, on pediatric patients suffering from hydrocephalus including 40 patients treated between January 2018 and January 2020, having predisposing factors for shunt exposure,operated upon by the technique of elevating a pericra-nial flap and the sub-pericranial shunt valve placement. Results: Out of the 40 patient included in the study, none of the cases developed any breakdown of skin or liability for exposure, with viable and healthy skin flaps, all cases had good wound healing, most of the cases requiring shunt insertion do so in the 1st 6 monhts of age, congenital hydrocephalus (60%) was the main etiology for shunt insertion followed by post infection & post-hemorrhagic etiology, most of the cases (80%) were below weight for age, 3 cases (7.5%) of cases developed shunt malfunctioning requiring revision (2 proximal, 1 distal), 2 cases (5%) had mild superficial wound infection resolved afterward, none of the cases developed Cerebrospinal Fluid (CSF) leak. Conclusion: Sub-periosteal shunt reservoir placement is simple, easy, non-time consuming, yet was very effective in reducing the nightmare of shunt exposure & CSF leak in predisposed malnourished or premature pediatric patient, abolishing the costly and exhausting need for reoperation and shunt transfer or skin grafting and risks of CSF infection.

Background: Hydrocephalus (HC) is a common neurological disorder presenting in infancy, with a myriad of etiologies requiring early neurosurgical intervention. Objective: To study neurodevelopmental outcome in patients with HC with shunt surgery done in infancy. Materials and Methods: This was an observational retrospective cohort study of 50 pediatric patients (2 years to 16 years of age). These patients were diagnosed with HC and were operated on with ventriculo-peritoneal shunt (VP shunt) insertion in infancy (did not include patients with brain tumors) and then later following in the neurology outpatient department (OPD). Clinical records and neurodevelopmental assessment (intelligence quotient [IQ]/development quotient [DQ] and vision and hearing assessment) were reviewed. Results: Only 50% of the patients with congenital HC were diagnosed at birth, which included patients who had been diagnosed antenatally and they had lesser complications and better intellectual outcome (P = 0.12), compared with those who presented later with HC. Patient-related factors such as etiology of HC, antenatal diagnosis, and requirement of shunt revisions had poor correlation with neurodevelopmental outcome. Patients with late postoperative complications had significantly poor neurodevelopmental outcome (P ≤ 0.001). Patients with post-meningitis HC required a significantly higher number of shunt revisions than patients with other causes (P = 0.04). Conclusion: Better neurodevelopmental outcome depends on early diagnosis and early referral for the management than the cause of HC. Regular head circumference monitoring is the most feasible and sensitive screening tool for early pickup. Larger studies are needed for accurate prognostication.