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A subset of patients with neurologic deficits require ventriculoperitoneal shunt (VPS) placement in addition to gastrostomy tubes (GTs). At present, the literature is inconsistent with respect to the sequence and time period between procedures that yields the lowest risk profile for GT and VPS placement. The purpose of this systematic literature review was to determine if time elapsed between VPS and GT placement was associated with infection (peritoneal and/or CSF). A systematic literature review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 guidelines. PubMEd/MEDLINE, Scopus, Ovid, Cochrane, and EMBASE databases were queried. Precise search terminology is available in the body of the manuscript. The initial database query yielded 88 unique articles. After abstract screening, 28 articles were identified and 6 met criteria for inclusion in the final analysis. The included studies were all retrospective analyses and reported data for 217 patients between the years of 1988 and 2016. Across all included studies, the infection rate after VPS and GT placement during the studies’ surveillance period was 15.2% (n = 33/217). The cumulative rate of all reported complications in patients with both VPS and GT was 24.0% (n = 52/217). These studies suggest that placement of GT in patients with preexisting VPS does not significantly contribute to increased shunt or intraperitoneal infection. Future studies should determine the optimal time interval between VPS and GT placement and to identify the most appropriate prophylactic antibiotic regimen.

Background Intraventricular Haemorrhage (IVH) is bleeding into the ventricles and is common in preterm neonates. An increasing grade of IVH is associated with poorer neurological outcomes. Bilateral Grade 4 IVH is associated with the poor prognosis and high rate of cerebral palsy. However recent research has shown that infants with unilateral grade 4 lesions had improved cognitive scores and better overall neurodevelopment outcomes. Objectives To retrospectively assess outcomes at 2 years according to degree of severity of Grade 4 IVH in preterm infants. Methods Design: Single-centre tertiary neonatal unit. 64 infants admitted between 2006 and 2019 confirmed to have IVH with parenchymal infarction (Grade 4 IVH). Method: Extent of infarction (PVHI) was further graded into ‘localised’ or ‘extensive’ (Volpe 2017). Two-year follow up for the inborn infants - Health Status Questionnaire, Schedule of Growing Skills, CP classified by site and GMFCS. Results Overall mortality 40/64 (63%) - localised group 10/21 (48%); extensive 30/43 (70%). Mortality was significantly higher in the extensive infarction group (p No infants with bilateral parenchymal infarction survived to discharge (n=8). Shunt placement in 4 (all extensive). 17/47 inborn survivors (8 extensive, 9 localised). Two-year outcome data cognitive assessment was available for 10/17. Further information available on 4 others (not yet 24 months). All infants with extensive infarction had CP (5/5). Localised infarction CP in 3/9 (33%) (p Overall disability (n=14): Free of disability in localised group 5/9 (55%), extensive: 0/5 (0%). Severe disability in localised group 0/9 (0%), extensive 2/5 (40%) Conclusions Although having a Grade 4 IVH still carries a high mortality rate, significantly better outcomes were seen with a localised Grade 4 IVH, important information in making critical care decisions.

We report the case of a 48-year-old man with spina bifida and history of previous ventriculoperitoneal (VP) shunt placement for hydrocephalus. On attempted removal of the shunt 2 years prior to presentation at a neurosurgical unit, the peritoneal component was left in situ due to difficulties with removal. He presented acutely to our general surgical department with an enterocutaneous fistula precipitated by the retained fragment discharging to the right upper abdominal quadrant that required urgent surgical intervention. Although abdominal complications of VP shunts are documented, there is minimal literature as to the risks of remnant catheters being left in situ. This case demonstrates the possible risks with retained VP shunt catheters and the necessity to remove any redundant foreign bodies to prevent significant delayed complications.

BACKGROUND Ventriculoperitoneal shunt (VPS) placement into the reoperative abdomen can be challenging due to intraperitoneal adhesions. Laparoscopic guidance may provide safe abdominal access and identify an area for optimal cerebrospinal fluid drainage. The study aim was to compare laparoscopic-assisted VPS placement to an "open" approach in patients with prior abdominal surgery. MATERIALS AND METHODS A retrospective review was performed of children undergoing VPS placement into a reoperative abdomen from 2009-2019. Clinical data were collected, and patients undergoing laparoscopy (LAP) were compared to those undergoing an open approach (OPEN). RESULTS A total of 120 children underwent 169 VPS placements at a median age of 8 y (IQR 2-15 y), and a mean number of two prior abdominal operations (IQR 1-2). Laparoscopy was used in 24% of cases. Shunt-related complications within 30 d were lower in the LAP group (0% versus 19%, P = 0.001), as were VPS-related postoperative emergency department visits (0% versus 13%, P = 0.003) and readmissions (0% versus 13%, P = 0.013). Shunt malfunction rates were higher (42% OPEN versus 25% LAP, P = 0.03) and occurred sooner in the OPEN group (median 26 versus 78 wk, P = 0.01). The LAP group demonstrated shorter operative times (63 versus 100 min, P < 0.0001), and the only bowel injury. Time to feeds, length of stay, and mortality were similar between groups. CONCLUSIONS Laparoscopic guidance during VPS placement into the reoperative abdomen is associated with a decrease in shunt-related complications, longer shunt patency, and shorter operative times. Prospective study may clarify the potential benefits of laparoscopy in this setting.

brain4care, a new Food and Drug Administration (FDA)-cleared non-invasive sensor that monitors intracranial pressure waveforms, was used in a 13-year-old girl who presented with untreatable headaches. The patient had a history of craniopharyngioma resection and a ventriculoperitoneal shunt placement 7 years prior to the use of the device. Secondary obstructive hydrocephalus was also a present factor in the case. The hypothesis was that due to the hydrocephalus, the child presented chronic headaches and needed constant readjustment into the ventriculoperitoneal shunt to regulate the cerebrospinal fluid inside her ventricles in order to control the patient's intracranial pressure (ICP). The device was chosen considering the risks to submit a patient into the regular invasive method to measure ICP. It was identified that the device could also indicate altered intracranial compliance due to the ratio between the P1 and P2 amplitudes (P2/P1 ratio > 1).

Ever since the shunt device became the gold standard treatment for hydrocephalus, complications due to infections and mechanical problems have increased while lives have been saved. In addition, abdominal complications have become an important issue as the peritoneum is now the main place to insert the distal catheter. The most common complications were abdominal pseudocyst, distal catheter migration, inguinal hernia, catheter disconnection, and intestinal obstruction. The pediatric population is more prone to develop most of these complications due to their rapidly growing body, weaker abdominal musculature, and increased intraabdominal pressure. The goal of this review was to study the main aspects associated with abdominal complications after ventriculoperitoneal shunt (VPS) insertion, including the pathophysiology, epidemiological aspects, as well as the rationale for management and prevention according to the current “state-of-the-art.” It is paramount to recognize the risk factors associated with various types of complications to manage them properly.

Classically, IIH patients with visual loss or severe symptoms have undergone cerebrospinal fluid shunt surgeries to reduce intracranial pressure. Shunts are helpful in reducing intracranial pressure and alleviating symptoms but are prone to failure. In this chapter, we take an in-depth look at the different types of shunts and shunt technologies that are used. We review the advantages and disadvantages of the different types of shunts and explore why shunts tend to malfunction and how doctors evaluate and treat patients with symptoms that return after shunt placement.

Distal shunt tube migration following ventriculoperitoneal (VP) shunt placement in children is mostly managed by an initial shunt diversion/removal and subsequent replacement. Lately, shunt salvage is being used as an alternative in certain conditions. We have focused on the situations where one can consider or disregard shunt salvage in such cases. A retrospective study of children treated for distal shunt migration following VP shunt placement between January 2013 and December 2019. Seventeen children were managed for over 7 years. These included cutaneous extrusions (n = 4), hollow viscus perforation (n = 6), inguinal hernias (n = 5), and umbilical extrusion (n = 2). The surgical treatment varied from a cutaneous wound closure (with a tube in situ), temporary external shunt diversion, and laparotomy with shunt reposition into the peritoneal cavity. Shunt salvage was possible in three cases, whereas in 2 cases even though shunt salvage was possible, it was not feasible due to a short residual shunt length. VP shunt salvage is possible in certain cases of distal shunt migration with a functional uninfected shunt. Small cutaneous extrusions can be covered by a local skin flap. Also, one should consider the residual intraperitoneal shunt length before its salvage in small children.

Shunt malfunctions seem more frequent in children (44 to 81%) than in adults (18 to 29%). Because of discrepancies between studies, it is not possible to affirm this disparity. The objective was to verify whether the incidence of cerebrospinal fluid (CSF) shunt malfunctions is higher in children than adults. We present a retrospective series of child and adult patients who underwent CSF shunt placement between 2000 and 2013 with a Sophysa SM8® valve. 599 adults and 98 children (sex ratio 1.28) underwent CSF shunt placement. Age at first surgery ranged between 1 day of life and 90 years (mean of 55.8 years, SD 25.8, median 64.8 years). The mean follow-up was 4 years (SD 4.264, 0–16; median 3 years). The cumulative complication rate was 25.5% (178/697). Mechanical complications were disconnection (25.1%), migration (11.8%), intracranial catheter obstruction (8.9%) and malposition (8.4%). The mean delay for the first revision was 1.90 years (0–13.9), (SD 2.73, median 0.5). The probability of shunt failure was 65% at 10 years in the child group and 36% at 10 years in the adult group. Moreover, in the child group, 33% of revisions occurred during the first year after shunt placement versus 17% in the adult group. Thus, the probability of shunt failure was higher in children than in adults (log-rank test, p < 0.001). This is the first retrospective study, comparing children and adults undergoing CSF shunt using the same valve, able to confirm the higher rate of complications in children.

Background Ventriculoperitoneal shunt (VPS) placement is one of the most frequent neurosurgical procedures and the operation is performed in a highly standardised manner under maintenance of highest infection precautions. Short operation times are important since longer duration of surgery can increase the risk for VPS complications, especially infections. The position of the proximal ventricular catheter influences shunt functioning and survival. With freehand placement, rates of malpositioned VPS are still high. Several navigation techniques for improvement of shunt placement have been developed. Studies comparing these techniques are sparse. The aim of this study is to prospectively compare ultrasound (US) guided to stereotactic navigated shunt placement using optical tracking with the focus on operation time and efficiency. Methods In this prospective randomised, single-centre, partially-blinded study, we will include all patients undergoing VPS placement in our clinic. The patients will be randomised into two groups, one group undergoing US-guided (US-G) and the other group stereotactic navigated VPS placement using optical tracking. The primary outcome will be the surgical intervention time. This time span consists of the surgical preparation time together with the operation time and is given in minutes. Secondary outcomes will be accuracy of catheter positioning, VPS dysfunction and need for revision surgery, total operation and anaesthesia times, and amount of intraoperative ventricular puncture attempts as well as complications, any morbidity and mortality. Discussion To date, there is no prospective data available comparing these two navigation techniques. A randomised controlled study is urgently needed in order to provide class I evidence for the best possible surgical technique of this frequent surgery. Trial registration Business Administration System for Ethical Committees (BASEC) 2019-02157, registered on 21 November 2019, https://www.kofam.ch/de/studienportal/suche/88135/studie/49552; clinicalTrials.gov: NCT04450797, registered on 30 June 2020.

Ventriculoperitoneal (VP) shunt complications involving the breast are rare, with the majority involving the formation of a cerebrospinal fluid pseudocyst. We present the case of a 22-year-old woman with recurrent cerebrospinal fluid pseudocyst secondary to fracture of a VP shunt at the time of breast surgery for breast asymmetry. We review the literature on this topic and present our case that highlights the need of the breast surgeon to take into account the position of VP shunts placed at birth. Shunts placed on the chest wall may result in breast asymmetry requiring surgery in the adolescent. Shunts in place since birth may be at greater risk of fracture during breast implant placement due to manipulation of a calcified and fragile shunt leading to formation of a cerebrospinal fluid pseudocyst.

Objective: After ventriculoperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (iNPH) with adjustable gravitational valves, a certain proportion of patients develop secondary clinical worsening after initial improvement of clinical symptoms. The aim of this study was to analyze this[for full text, please go to the a.m. URL], 71. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC), 9. Joint Meeting mit der Japanischen Gesellschaft für Neurochirurgie

Frequency and duration of outpatient clinic follow-up for patients with shunted hydrocephalus varies among clinicians and assessment of follow-up regimens is lacking. The aim of this study is to investigate whether routine clinic visits alter care and whether they identify patients requiring shunt revision surgery, as well as, to better understand how patients utilize the outpatient clinic and present for shunt revision evaluation. This is a single-centered retrospective study of 154 patients requiring shunt revision surgery from 2009 to 2018 who had at least one prior clinic evaluation. The median age for shunt placement and revision were 3 months and 11 years old, respectively. Routine clinic visits led to a change in care for 16 patients (10.4%); including additional imaging, follow-up, or a combination of the two. With regards to revision surgery, days from prior shunt surgery, Chiari II/myelomeningocele pathology, and shunt type (p 0.01) did affect time to presentation. Four patients (2.6%) requiring revision surgery were identified at routine clinic follow-up, while 92 (59.7%) and 47 (30.5%) presented to the emergency department and clinic sick visit, respectively. Presentation to clinic resulted in a statistically significant decrease in shunt revision surgery length-of-stay compared to presentation to the emergency department or inpatient admission for another condition. Even with increased emergency room utilization, increased clinic connectivity, and improved patient education, routine clinic visits remain an important component in the follow-up of patients with shunted hydrocephalus by helping to guide clinical care and identify patients requiring shunt revision surgery.

Background Several case series and case reports have been published about idiopathic hydrocephalus treatment in dogs and cats using ventriculoperitoneal shunts (VPS). Objectives To determine the risk and type of complications in dogs and cats after VPS placement. Animals Sixteen papers were included. Sixty dogs and 13 cats with idiopathic hydrocephalus treated by VPS placement were identified. Methods The databases CAB, Scopus, and Medline were used. Idiopathic/congenital hydrocephalus, feline/canine patients, ventriculoperitoneal shunting, complications, and outcomes were inclusion criteria. The focus was on complication type and time frame within which they arose. Results Complications in dogs (n = 60) were shunt obstruction (6/60; 10%), pain (4/60; 5.5%), shunt infection (3/60; 4.1%), disconnection (3/60; 4.1%), excessive shunting (2/60; 2.7%), and kinking (1/60; 1.6%). Complications in cats (n = 13) were coiling of the shunt in the SC tissue (2/13; 15.4%); kinking (1/13; 7.7%); and shunt obstruction (1/13; 7.7%). Complications were most likely during the first 6 months after shunt placement. Conclusion and clinical importance Ventriculoperitoneal shunting is considered a viable treatment option for patients with hydrocephalus. Potential complications should be discussed with the owner. Early diagnosis of complications is essential.

Meningomyelocele is a serious pathology that requires immediate surgical treatment. Its management is difficult due to accompanying other pathologies and hydrocephalus. Shunt timing is still controversial. Therefore, this study retrospectively assessed 80 patients in order to improve the shunt timing and management of patients with meningomyelocele. A total of 80 patients were followed up for 18–48 (average, 23) months. Patients were analyzed for the following variables: delivery method and time, head circumference monitoring, shunt timing, complication rates of patients who underwent shunting, during the early or follow-up period, accompanying pathologies, size, and localization of lesion. Patients including 46 males and 34 females have been operated. In 40% of patients, the accompanying pathology was determined. Approximately 85% of patients had hydrocephalus, and a ventriculoperitoneal shunt was placed on 36 symptomatic and 22 patients with hydrocephalus that developed during the follow-up. Differences in shunt-related and general complications were not significant between patients who underwent shunt placement during the same session and patients who underwent shunt placement during the follow-up. However, the incidence of cerebrospinal fluid fistula formation from the wound in patients who underwent shunt placement during the same session was significantly lower than those who underwent shunt placement during follow-up. Immediate surgery (within the first 48 h) provides positive results, which is consistent with the existing literature. According to the logistic regression analysis, the placement of the meningomyelocele sac in the lumbosacral region is decisive in shunt insertion. Placing the shunt in the same session for patients with hydrocephalus and later for patients who developed hydrocephalus during the follow-up is recommended as a favorable treatment.

Ogilvie’s syndrome is a rare postoperative condition commonly referred to as a “colonic pseudo-obstruction” due to the absence of mechanical obstruction. It should be a differential for patients over the age of 60 years who present with nausea, vomiting, and colonic dilatations on imaging. Ogilvie’s syndrome following a ventriculoperitoneal (VP) shunt placement is an extremely rare entity with only one other adult patient reported in the English literature. In this case report, we explore the diagnosis and management of a 76-year-old patient who presented with abdominal pain and multiple bouts of bilious, non-bloody vomitus two days after a ventriculoperitoneal shunt. The ultimate diagnosis of Ogilvie's syndrome along with imaging and subsequent management is detailed, and diagnosis guidelines and treatment options for Ogilvie's syndrome are analyzed and explained. This case highlights the importance of keeping Ogilvie's syndrome on the list of differentials in a postoperative patient in all abdominal surgeries, even if they are minimally invasive.

Hydrocephalus is a common complication after decompressive craniectomy (DC) in patients with traumatic brain injury (TBI). However, the strategy of managing TBI patients with a cranial defect and hydrocephalus remains controversial. Placement of a ventriculoperitoneal shunt (VPS) in patients with a cranial defect and hydrocephalus may aggravate sinking skin flap overlying the cranial defect and result in syndrome of sinking skin flap (SSSF) that causes neurological deterioration. A retrospective analysis of 49 TBI patients who developed hydrocephalus after unilateral DC was undertaken to investigate the safety of simultaneous cranioplasty and VPS placement, and the incidence of SSSF after VPS placement. Among these patients, 17 patients underwent simultaneous cranioplasty and VPS placement, and 32 patients underwent staged cranioplasty and VPS placement. The overall complication rate was 9.3% (3/32) in staged group and 29.4% (5/17) in simultaneous group, respectively. There was no statistically significance between two study groups regarding overall complication (p = 0.11) and reoperation rate (p = 0.47). Two patients with severe brain bulging in staged group developed SSSF after placement of a nonprogrammable VPS. Our study showed that simultaneous cranioplasty and VPS placement may be safe in TBI patients with a cranial defect and hydrocephalus. However, due to the contradictory results about the safety of simultaneous cranioplasty and VPS placement in the literatures, neurosurgeons should carefully consider whether patients are suitable for such treatment. In patients planning to undergo VPS placement first, a programmable shunt may be a better choice for the possibility of SSSF after shunt placement.

Normal pressure hydrocephalus (NPH) is generally treated with ventriculoperitoneal shunts (VPS), with improved symptoms in the majority of patients. We performed a retrospective chart review study in order to describe patterns of, and risk factors for, delayed symptom progression after initially successful VPS placement. 69 consecutive patients underwent VPS placement for NPH, and were followed for a minimum of 12 months postoperatively. 55 patients (80%) had objective improvement in their NPH symptoms after surgery. Of these, 27 patients (49%) developed delayed deterioration of at least one of their NPH symptoms, at a mean of 28.3 months postoperatively (range, 3–77). 1 of the 27 patients was found to have shunt malfunction; 19 had specific clinical or imaging evidence of shunt function. 6/19 patients had transient improvement in their symptoms (lasting 30 days or more) after adjustment of their programmable shunt valves (32%), although symptoms in all of these patients later worsened. During a mean follow up period of 44.4 months (range, 15–87), 12 patients (44%) received other neurological diagnoses felt to at least partially explain their symptoms. Increased patient age was associated with likelihood of delayed symptom progression. We conclude that delayed symptom progression is common after VPS placement for NPH, including after initial symptom improvement; that symptom progression can often be temporarily palliated by shunt valve pressure adjustment; and that older patients are more likely to experience delayed symptom progression. We suggest that patients and their families be counselled accordingly before surgery.

Objective The Barrow Innovation Center consists of an educational program that promotes interdisciplinary collaboration among neurosurgery, legal, and engineering professionals to foster the development of new medical devices. This report describes a common issue faced during the placement of ventricular shunts for the treatment of hydrocephalus and the solution to this problem that was developed through the Barrow Innovation Center. Methods Neurosurgery residents involved in the Barrow Innovation Center presented the problem of ferromagnetic retractors interfering with pinless image-guidance systems at a monthly meeting. Potential solutions were openly discussed by an interdisciplinary committee of neurosurgeons, patent lawyers, and biomedical engineers. The committee decided to pursue development of a novel self-retaining retractor made of nonferromagnetic material as a solution to the problem. Results Each retractor design was tested in the cadaver laboratory for size and functionality. A final design was chosen and used in a surgical case requiring ventriculoperitoneal shunt placement. The new retractor successfully retracted the scalp without interfering with the electromagnetic image-guidance system. Conclusions Through the interdisciplinary Barrow Innovation Center program, a newly designed, 3-dimensional–printed skin and soft-tissue retractor was created, along with an innovative universal shunt retainer. Through this integrated program dedicated to surgical innovation (i.e., the Barrow Innovation Center), the process of developing and implementing new technology at our institution has been streamlined, creating a culture of innovation within the neurosurgery training program.

Background Shunt infection (SI) is a dreaded and major complication in the management of hydrocephalus after cerebral fluid shunts. We reviewed retrospectively shunted for hydrocephalus during the last 2 years to evaluate the incidence of SI, including the risk factors and types of infection. Methods Patients who had undergone a shunt operation from January 2013 to December 2014 in our hospital were observed, study clinical data and a 6-24 months follow-up. Patients with infection complications were found and investigated. Results Among 343 cases of shunt surgery performed in our hospital, 6–24 months follow-up was done. 13 patients (10 men and 3 women) were found shunt infections, 11 (3.7%) were post-operation of ventriculo-peritoneal shunt and 2 (4.2%) of lumbo-peritoneal shunt.92.3% cases of shunt infections were present within 2 months after shunt surgery, gram positive cocci accounted for 90% of the bacteria. After different surgery and antibiotic treatment, 8 patients became better and 5 worse. Conclusions The data in our single institution shows no significant differences between sex and shunt surgery. Infections more likely to present within the first 2 months after shunt placement, and gram-positive cocci account for a great proportion in detected bacteria.

Cerebral cysticercosis is common, but the possibility for repeated occurrence of peritoneal catheter blockage caused by neurocysticercosis (NCC) after two revisions following ventriculoperitoneal shunt placement for hydrocephalus is unusual. Herein, we describe one rare case in which peritoneal catheter revision was performed two times unsuccessfully. Endoscopic cysternostomy rather than peritoneal catheter adjustment was performed successfully, and histopathological examination of excised cystic samples confirmed NCC in our hospital. The present case highlights the need for awareness of NCC as a possible etiology of hydrocephalus, especially in developing countries. Uncommon findings in both lateral ventricles following low-field magnetic resonance imaging scans as well as the rarity of this infection involved in unusual location play important roles in misdiagnosis and incorrect treatment for hydrocephalus; thus, endoscopic cysternostomy, rather than multiple shunt adjustment of the peritoneal end, is recommended in the selected patient. To the best of our knowledge, this is the first report describing the misdiagnosis and inappropriate treatment of hydrocephalus caused by cerebral cysticercosis in China.

Purpose There have been previous case reports suggesting the resolution of both sensorineural hearing loss and retrocochlear involvement through the management of hydrocephalus with shunt placement. This is a case report of a patient with Auditory Neuropathy Spectrum Disorder (ANSD) that resolved after shunt placement in a patient with hydrocephalus. Materials and methods Chart review of a single patient with a diagnosis of ANSD and hydrocephalus. Type of audiometric testing and results were document. Results Patient is an infant who was diagnosed with hydrocephalus at birth and ANSD in the right ear at 3 months of age. Patient underwent shunt placement at 9 months old and had behavioral testing 2 months later. Audiometry showed normal behavioral audiometric thresholds with presence of ipsilateral and contralateral reflexes which is suggestive of resolution of ANSD. Conclusions This is a single case report of resolution of ANSD after shunt placement in a patient with hydrocephalus. Close monitoring and repeat audiological evaluation is recommended to follow these patients.

Background Entrapment of the temporal horn, known as isolated lateral ventricle (ILV), is a rare type of noncommunicating focal hydrocephalus, and standard treatment has not been established. We report 2 cases of endoscopic surgery for ILV and highlight the anatomic surgical nuances to avoid associated surgical risks. Case Description The first patient presented with recurrent ILV following initial shunt placement for ILV, owing to shunt malfunction. In the second patient, ILV recurred secondary to choroid plexus inflammation caused by cryptococcal infection. Endoscopic temporal ventriculocisternostomy was effective in both cases. However, in the second case, the choroidal fissure was fenestrated, which led to cerebral infarction in the territory of the choroidal artery zone, attributed to damage of the branches of the choroidal segment of the anterior choroidal artery. Conclusions Although endoscopic temporal ventriculocisternostomy is considered a safe and less invasive procedure for treatment of symptomatic ILV, the technique is still associated with risks. To avoid complications, it is necessary to be familiar with the anatomy of the choroidal arteries and the pertinent endoscopic intraventricular orientation. Additionally, sufficient experience is required before it can be recommended as the treatment of choice.

Permanent cerebrospinal fluid diversion has a lengthy list of complications. We present an unusual clinical image of shunt catheter migration. A 54-year-old female had a history of subarachnoid hemorrhage that resulted in communicating hydrocephalus, which needed a ventriculoperitoneal shunt placement. On outpatient follow-up, she was found to have a sunken skin flap that was resistant to raising the shunt valve setting. A radiograph of the shunt system revealed that the peritoneal catheter had migrated into the thoracic cavity. On review of the patient's previous imaging, an area indicative of a minor pleural breach was identified that exposed the catheter to the negative thoracic pressure, which resulted in progressive catheter migration. The patient then underwent removal of the shunt system since her hydrocephalus had resolved. A pleural breach during shunt placement can result in the migration of the shunt catheter into the thoracic cavity under the effect of negative thoracic pressure.

PURPOSE Most patients with spina bifida require ventriculoperitoneal (VP) shunt placement. Some also require bladder augmentation, which may increase the risk of VP shunt malfunction and/or failure. The aim of this study was to assess whether bladder augmentation affects the rate of VP shunt failure in this population. METHODS Using the Pediatric Health Information System, we studied patients with spina bifida born between 1992 and 2014 who underwent VP shunt placement. Using conditional logistic regression, we compared age- and hospital-matched patients who did and did not undergo a bladder augmentation to determine their difference in rates of VP shunt failure. RESULTS There were 4192 patients with spina bifida who underwent both surgical closure and VP shunt placement. Of these, 203 patients with bladder augmentation could be matched to 593 patients without bladder augmentation. VP shunt failure occurred within 2 years in 7.7% of patients, the majority of whom were in the group who underwent bladder augmentation (87%). After adjusting for confounders, undergoing bladder augmentation was independently associated with VP shunt failure (HR: 33.5, 95% CI: 13.15-85.44, p< 0.001). CONCLUSION Bladder augmentation appears to be associated with VP shunt failure. Additional studies are necessary to better define this relationship and identify risk-reduction techniques.

Background: Isolated lateral ventricle is a specific form of non-communicating hydrocephalus that is caused by an obstruction of the foramen of Monro. The condition was previously treated with bilateral shunt placement. However, the emergence of endoscopic surgery has provided more options in the management of this condition. Case description: 46-year-old female presented with obstructive hydrocephalus caused by a right thalamic primary central nervous system B-cell lymphoma. Endoscopic septostomy with unilateral shunt placement was performed because of bilateral foramen of Monro obstruction. Conclusion: Endoscopic septostomy can be used as a tool to avoid bilateral shunt placement in certain cases of bilateral isolated lateral ventricles. Keywords: Septostomy, CNS lymphoma, Endoscopic surgery, Isolated ventricles

Ascites causes significant discomfort and has negative impact on patient's quality of life. Medical therapies including dietary restriction and diuretics are successful in only 40 to 44% of patients with malignant ascites and repeated paracentesis only provides temporary symptomatic relief. Therefore, a more permanent solution is necessary. Indwelling catheters or peritoneovenous shunt placement can provide more permanent symptomatic relief and improve patients' quality of life. Unlike indwelling catheters, peritoneovenous shunts do not limit patients' life style and therefore should be offered as first option in patients who are good candidates. Denver shunt (CareFusion-BD Worldwide) is the current available peritoneovenous shunt. In this article, the indications, contraindications, technical aspects of shunt placement, and techniques to prevent postprocedure complications will be discussed.

Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt placement are two surgical options used for treatment of non-communicating hydrocephalus. The purpose of this study was to compare the efficiency and safety of these techniques in pediatric patients.An extensive literature review regarding the clinical outcome, safety, and efficiency of ETV and shunting in treatment of hydrocephalus was conducted in Medline, PubMed, Cochrane, and Google Scholar databases up to November 27A total of 7 two-arm studies were included for quantitative analysis and 25 single-arm studies were included for systematic review. The two-arm studies recruited a total of 6995 patients: 1046 in the ETV group and 5949 in the shunt group. The pooled results showed that the 1 year success rate of ETV and shunt-placement procedure were similar (pooled RR = 0.870, 95% CI = 0.680 to 1.112, P = 0.266). The failure rate in the ETV treatment group was 0.9 times higher than in the shunt group; however, the results did not reach statistical significance (pooled RR = 0.893, 95% CI = 0.576 to 1.383, P = 0.611).Both ETV and shunts are associated with similar 1 year success and failure rates. Therefore, there are no current indications to recommend one mode of treatment over the other. Future studies designed to assess the effectiveness of ETV and shunt procedures depending on patient's age and etiology are warranted.

Subdural hematomas commonly recur after surgical evacuation, at a rate of 2% to 37%. Risk factors for recurrence can be patient related, radiologic, or surgical. Patient-related risk factors include alcoholism, seizure disorders, coagulopathy, and history of ventriculoperitoneal shunt. Radiologic factors include poor brain reexpansion postoperatively, significant subdural air, greater midline shift, heterogeneous hematomas (layered or multi-loculated), and higher-density hematomas. Surgical factors include lack of or poor postoperative drainage. Most recurrent hematomas are managed successfully with burr hole craniostomies with postoperative closed-system drainage. Refractory hematomas may be managed with a variety of techniques, including craniotomy or subdural-peritoneal shunt placement.

Objective Coccidioidomycosis is a fungal infection endemic to the southwestern United States. Hydrocephalus can develop after intracranial dissemination, and management of this disease entity is difficult. We present our institutional experience with shunting coccidioidomycosis-related hydrocephalus. Methods A cohort of patients with coccidioidomycosis-related hydrocephalus undergoing an intracranial shunt placement were retrospectively identified over a 24-year period. Demographics and treatment characteristics were obtained from the electronic medical record. Results Thirty patients undergoing 83 procedures were identified, with a median follow-up of 19.4 months. The average age of the cohort was 43 years at the time of initial shunt placement. Most patients (66.7%) had ≥1 shunt failure, and the average number of revisions required was 2.6 for patients who had shunt failure. The average shunt valve pressure threshold required was 5.5 cm H2O, and patients who harbored the disease for a longer period (>7 months) had a lower pressure setting for initial shunt valves. Shunts without an antisiphon component were more likely to be failure free on multivariate analysis (odds ratio, 9.2; 95% confidence interval, 2.4–35.7). Death was associated with a longer diagnosis-to-shunt time interval, and patients having been diagnosed with intracranial disease for more than 10 months before shunt placement had significantly higher rates of death on follow-up. Conclusions Patients with coccidioidomycosis-related hydrocephalus typically have normal to low pressure setting requirements, high shunt failure rates, prolonged hospitalizations, and mortality. In this disease context, shunt valves without an antisiphon component are associated with lower shunt failure rates.

Neurocysticercosis is the most frequent parasitic disease of the central nervous system, and its incidence in the developed countries is increasing due to immigration and travels from endemic areas. The intraventricular location has been found to involve up to 61.3% of the patients; moreover, only 22 cases of migrating intraventricular cyst have been reported so far. Despite the rarity of the condition in western countries, its occurrence generates some concerns and the aim of this paper is to update the information concerning pathogenesis, clinical presentation, diagnosis and management of this entity. All the pertinent literature was analysed, focused on the cases of migrating intraventricular neurocysticercosis and its peculiar features. An illustrative case regarding a 14-year-old girl is also presented. Migrating intraventricular neurocysticercosis is a pathognomonic entity usually presenting with hydrocephalus, and its treatment is mainly surgical, preferring an endoscopic approach. When the resection of the intraventricular cyst is not performed, an accurate follow-up is mandatory to detect clinical changes due to a recurrent hydrocephalus or to the effect of the dying cyst on the surrounding area. In case of permanent shunt placement, the cysticidal and steroid treatment is recommended to reduce the risk of shunt failure.

Background: Endoscopic third ventriculostomy (ETV) approach was gaining popularity over shunt placement in obstructive hydrocephalus. Postoperative ETV assessment and patients follow up remains a matter of controversy and challenge to ensure efficiency and patency of ventriculostomy. Aim of the work: To assess whether cerebrospinal fluid (CSF) flow is restored after ETV and similarity to flow in normal aqueduct with patients clinical and ventricular size changes assessment. Patients and Methods: From April 2016 to April 2019, 30 patients with hydrocephalus due to aqueductal stenosis (AS) were treated with ETV. They were followed up for ventriculostomy patency within the 1st, 6th and 9th month after surgery and compared to 22 persons as a control group of normal aqueductal flow with phase contrast magnetic resonance imaging (PC MRI). Results: Twenty-three (23) patients restored pulsatile bidirectional pattern of CSF flow across the ventriculostomy similar to that of aqueductal flow. While one patient had no flow during the 1st follow up and 6 patients showed initial pulsatile flow then developed flow disturbance during the 2nd follow up period. Absolute stroke volume values showed significant statistical difference between ETV and control groups (p value < 0.001). The value of 85 μl showed sensitivity and specificity of 84.3% and 81.7%, respectively as a cutoff value of ETV efficiency. Conclusion: ETV is an efficient technique to restores the physiological pulsatile Cerebrospinal fluid flow. Absolute stroke volume was a good predictor of ETV efficiency.

Ventriculoperitoneal (VP) shunt placement is one of the most commonly performed procedures in neurosurgery. One rare complication is the formation of an abdominal pseudocyst, which can cause shunt malfunction. Keyword: Abdominal Pseudocyst, Ventriculoperitoneal Shunt

A 10-year-old girl presented with excessive sweating overlying her right scapula (figure) and stable right leg weakness due to an underlying solid cystic pilocytic astrocytoma spanning T3–T12, debulked 5 months earlier, subsequently re-decompressed with syringosubarachnoid shunt placement secondary to intrasyrinx hemorrhage. MRI demonstrated mild tumor and syrinx progression at T5–T8, limited to the right side (figure, B–E). Focal segmental hyperhidrosis is rare, previously reported in Chiari and trauma-related syringomyelia.1,2 Here, unilateral hyperhidrosis was caused by ipsilateral tumor and syrinx progression. The pathophysiology may be from local tissue damage causing hyperactivity of preganglionic sympathetic neurons or disinhibition of inhibitory local interneurons.2

Ventriculoperitoneal (VP) shunt placement is one of the more common procedures in neurosurgery and has a variety of indications. However, shunt placement can be associated with multiple complications, one of which is proximal and distal shunt migration. There have been reported cases of migration of the distal end of a VP shunt from the intraperitoneal cavity into different organs resulting in a variety of complications. Most of the reported cases are the result of spontaneous migration. However, shunt catheter migration could be iatrogenic as well. We present a case of intragastric VP shunt migration in a patient following placement of a percutaneous endoscopic gastrostomy tube.

Background: Hydrocephalus is a common problem in neurosurgery with shunt placement remains the mainstay of the management. However, shunt placement generally requires following surgical procedures, including shunt revision. Despite the recent developments, the incidence of shunt failure remains high, approximately 30–51% in the 1st year following the shunt placement. Methods: An observational retrospective study of pediatric neurosurgery patients whom underwent CSF shunting procedure, both primary and repeated VPS, VAS, CPS, and subdural-peritoneal shunt procedures between January 2018 and May 2019. The patients were observed for 12 months for potential complication requiring shunt revision following the shunt placement. Results: A total of 142 patients underwent shunt placement. The shunt revision within 12 months was found in 26 patients (18.3%), 25 cases were VPS (96.2%) and one case was CPS (3.8%). The mean period of time between shunt placement to shunt revision was 3.96 months. Age of under 6 months old during the shunt placement showed significantly higher risk for shunt revision (RR 2.32 CI 1.13–4.74, P = 0.018). The most common diagnosis requiring shunt revision was congenital anomaly (16 cases, 61.5%). The most common cause of revision was shunt malfunction, with 21 cases (80.8%) followed by infected shunt with 5 cases (19.2%). Conclusion: The 1st year observation showed relatively high rate for shunt revision. The patient underwent shunt procedure should be regularly followed up in long period for better evaluation of the outcome. The application of shunt registry in some countries appears to be efficient and beneficial for sustainable follow-up in patients underwent shunt placement.

The ever present need to balance over drainage with under drainage in hydrocephalus has required innovations including adjustable valves with antigravity devices. These are activated in the vertical position to prevent siphoning. We describe a group of bedridden patients who presented with unexplained under drainage caused by activation of antigravity shunt components produced by peculiar head/body position. Retrospective single centre case series of hydrocephalus patients, treated with ventriculo-peritoneal (VP) shunt insertion between April 2014 - February 2016. These patients presented with clinical and radiological under drainage syndrome. Medical notes were reviewed for clinical picture and outcome. Radiological studies were reviewed assessing shunt placement and ventricular size. Seven patients presented with clinical and radiological under drainage syndrome. A consistent posturing of long term hyper-flexion of the neck whilst lying supine was observed. All patients had similar shunt construct (adjustable Miethke ProGAV valve and shunt assistant anti-gravity component). In each of those patients a hypothesis was formulated that neck flexion was activating the shunt assistance anti-gravity component in supine position. Five patients underwent shunt revision surgery removing the shunt assistant device from the cranium and adding an anti-gravity component to the shunt system at the chest. One had the shunt assistant completely removed and one patient was managed conservatively with mobilisation. All patients had clinical and radiological improvement. Antigravity shunt components implanted cranially in bedridden hydrocephalus patients will produce underdrainage due to head flexion induced anti-gravity device activation. In these patients, anti-gravity devices should be placed at the chest. Alternatively, special nursing attention should be paid to head-trunk angle.