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PubMed1977

Cerebrospinal fluid shunts.

Cerebrospinal fluid (CSF) shunt technology has undergone rapid advances in the past two decades. As a result, pediatricians and other primary care physicians are being asked with increasing frequency to provide care for persons with CSF shunts. Familiarity with the more common shunts is a prerequisite to intelligent management of shunt related problems. Physicians providing daily care must have carefully documented hospital records and operative notes available to them as well as information detailing the safe evaluation of shunt patency and function if they are to manage patients with CSF shunts properly. In addition, parents and guardians must be alerted to signs and symptoms related to shunt malfunction.

Cerebrospinal Fluid Shunts↗

PubMed2006

Biofilm-related infections of cerebrospinal fluid shunts.

Cerebrospinal fluid (CSF) shunts carry a high risk of complications. Infections represent a major cause of shunt failure. Diagnosis and therapy of such infections are complicated by the formation of bacterial biofilms attached to shunt surfaces. This study correlated the pathophysiology and clinical course of biofilm infections with microscopical findings on the respective shunts. Surface irregularities, an important risk-factor for shunt colonisation with bacteria, were found to increase over time because of silicone degradation. Scanning electron-microscopy (SEM) documented residual biological material (dead biofilm), which can further promote extant bacterial adhesion, on newly manufactured shunts. Clinical course and SEM both documented bacterial dissemination against CSF flow and the monodirectional valve. In all cases, biofilms grew on both the inner and outer surfaces of the shunts. Microscopy and conventional culture detected all bacterial shunt infections. Analyses of 16S rDNA sequences using conserved primers identified bacteria in only one of three cases, probably because of previous formalin fixation of the samples.

Adolescent↗

PubMed1993

The gravitational shunt: an alternative approach to cerebrospinal fluid shunting.

Current cerebrospinal fluid shunts use complex differential pressure values to regulate drainage. Such systems are prone to overdrainage and obstruction, and thus have an unpredictable effect on intracranial pressure (ICP). The gravitational shunt (GS) introduces an alternative approach. It uses a single, simple valve to balance the pressures generated within a vertical shunt system. The ICP is then regulated by the position of the valve along the cranioabdominal shunt axis and not by the mechanical properties of the valve. Bench testing demonstrated that when using the GS (1) a linear correlation (r = 0.91, p < 0.001) exists between the ICP and the position of the valve along the vertical shunt axis, (2) positive and negative ICPs are maintained, and (3) the ICP can be predicted by an equation derived from theoretical principles. The GS uses a single, simple valve as a pressure regulator and an antisiphon device. It allows the maintenance of a normal negative ICP in the upright position without risk of over-drainage. The other benefits of this system are discussed.

Cerebrospinal Fluid Shunts↗

PubMed2005

[The cerebrospinal fluid shunt].

The cerebrospinal fluid shunt is one of the most common surgical procedures in pediatric neurosurgery. Nevertheless, an important rate of failure (mechanical, infectious or functional) can occur. These complications can result from the hydrocephalus itself, the surgical technique (type of material and surgeon experience) and infectious problems related to foreign material. Most of the time, the clinical signs of these failures are obvious (intracranial hypertension or signs of meningitis) but can also be insidious.

Cerebrospinal Fluid Shunts↗

PubMed1998

Propionibacterium [correction of Proprionibacterium] acnes infections of cerebrospinal fluid shunts.

Ventricular cerebrospinal fluid shunt infections with Propionibacterium acnes are generally low-grade, indolent infections. Typical presentations include gradual shunt malfunction, nausea, headache, malaise, and infrequently, fever. In all, 489 shunt procedures performed between January 1992 and December 1995, and in 15 of these cases P. acnes was subsequently cultured from reservoir taps or an intraoperative culture which was obtained when the existing shunt components were revised. Six of these, representing 14.6% of shunt infections, were considered to be true P. acnes shunt infections, as they were associated with either CSF leukocytosis or the identification of gram-positive rods by gram stain. The others were considered to be probable contaminants. Detailed analysis of all 15 of these cases revealed that no patient had positive CSF cultures after removal of the infected shunt and the initiation of antibiotics. Given the benign characteristics of P. acnes shunt infections, the broad sensitivity to antibiotics, and the rapid sterilization of the cerebrospinal fluid, it may be possible to treat such cases with short-term perioperative antibiotics and replacement of the shunt components, in place of prolonged external ventricular drainage and antibiotics. This would have eliminated 8 operative procedures and reduced the estimated length of stay by 77 patient-days in these 15 children.

Adolescent↗

PubMed1990

The use of magnetic resonance imaging to assess slow fluid flow in a model cerebrospinal fluid shunt system.

Cerebrospinal fluid (CSF) shunt malfunction in patients with hydrocephalus is common and can result in prolonged hospitalisation, operative exploration or progressive neurologic damage. The evaluation of shunt function usually requires invasive techniques that can be inaccurate or cause complications. Magnetic Resonance Imaging (MRI), which has been used to study both intraluminal blood flow and intraventricular CSF flow, may offer an alternative noninvasive test of shunt function. The MR characteristics of flow related enhancement were studied in a model shunt system. A special section of tubing for MRI was inserted into the system proximal to the valve. Flow through the system could be varied from 0 to 20 ml/h. Multiple spin echo images were made (TR2000, TE20) transverse to the specialised tubing. The intensity of the intraluminal MR signal at specific locations along this tubing and from a 'no flow' standard were measured. The signal intensity varied as a linear function of flow rate from 2.5 ml/h to 20 ml/h. These results suggest that MRI has potential for evaluating the slow flow in CSF shunts.

Cerebrospinal Fluid Shunts↗

PubMed1994

Cerebrospinal fluid shunt infections.

Cerebrospinal fluid (CSF) shunt infection is one of the most frequent and disabling complications. We reviewed the records of 306 patients who underwent CSF shunt surgery from 1983 through 1992. Six hundred and twelve procedures were performed in these 306 patients. Infection occurred following 46 of the procedures for an infection rate of 7.5% per procedure. The 46 infections involved 39 patients. There were 8 recurrent infections. The infection rate per child was 12.7%. Staphylococcal species were isolated in 50% of all infections. Patients younger than 1 year old and children with multiple revisions have a greater risk of infection than those of older. Myelomeningocele and meningitis had higher infection rate among other etiologies. Patients with multiple revisions had higher infection rate than those with single revision or none. The incidence of infection was higher in cyst-peritoneal shunts than both ventriculo-atrial and ventriculo-peritoneal shunts. Mortality was high in Gram negative infections.

Adolescent↗

PubMed2002

Extremely rare complications in cerebrospinal fluid shunt operations.

The cerebrospinal fluid shunt operation, from its first realization in 1908 by Kausch till our days, is still of a significant importance for the long-term treatment of the internal hydrocephalus. Well known are many complications connected with the use of the valve systems (malfunction, infectious, overdrainage, secondary craniosynostosis and etc.). For a period of 17 years (1984-2000) at the Clinic of Pediatric Neurosurgery, Department of Neurosurgery, Sofia Medical University, 414 cerebrospinal fluid shunt operations were performed on children. 216 were drained to the right atrium of the heart, 198 to the peritoneal cavity. They were followed up by catamnesis until the year 2001. The authors describe 2 extremely rare cases with post-shunt complication as a result of a malfunction of the valve system, owing to a migration of the distal catheter: 1) in the anus; 2) in the urethra. In the first case the distal catheter perforated the colon transversum and by the way of the intestines went out through the anus. In the second case the distal catheter protruded out of the body through the bladder and the urethra. Their clinical appearance, the diagnostic examinations and the operative treatment are shown.

Child, Preschool↗

PubMed1994

The effect of position on magnetic resonance evaluation of cerebrospinal fluid shunt function.

Since cerebrospinal fluid shunt malfunction is common and its diagnosis often requires invasive testing, we have evaluated magnetic resonance imaging (MRI) as a noninvasive test for shunt function. In prior experiments, MRI has been shown to be capable of detecting flows as low as 0.4 cc h-1 in shunt systems. Because patient movement and position in an MRI scanner are variable, we have studied the effects of shunt position on the ability to reliably detect the rate of CSF flow. Flow related enhancement of fluid flowing from 0 to 2 cc h-1 was measured in a specialized section of tubing using multiple spin echo scans (TR2000,TE20). The angle of the specialized tubing was varied relative to the axis of the MRI scanner and then the intensity of the MR signal at specific points in the tubing was measured at different flow rates. No flow standards were used as controls. The results show that the linear relationship between signal intensity and flow that had previously been demonstrated was significantly altered by changes of position. Positions angled superior to the axis of the scanner enhanced the signal while lateral changes in the plane of the scan degraded the signal. These results suggest that in order for MRI to become an accurate test for shunt function, techniques must be developed to overcome the effects of shunt position.

Cerebrospinal Fluid Shunts↗

PubMed1991

Cerebrospinal fluid shunting for hydrocephalus in the adult: factors related to shunt revision.

Cerebrospinal fluid shunting procedures are widely employed in the treatment of hydrocephalus and other disturbances of the dynamics of cerebrospinal fluid. In spite of its popularity, this operation frequently requires surgical revision. A retrospective analysis of a series of 356 adults who underwent the insertion of a cerebrospinal fluid shunt between January 1970 and December 1988 was performed. The incidence of revision was analyzed, and an attempt was made to identify possible causal factors. The overall incidence of surgical revisions was 28.65%; the number of revisions in the same patient ranged between one and eight. The most frequent causes of revision were distal malposition, obstruction, and infection. A statistically significant difference (P less than 0.05) was found in both the risk of revision in patients who had undergone previous operations and those who had not and in the incidence of revision before and after January 1985. Meticulous surgical technique as well as perioperative antibiotic prophylaxis appear responsible for the latter. The differences in the incidence of revision among patients treated with different types of shunts and valves, though remarkable, is not statistically significant.

Adolescent↗

PubMed2003

Stretching and breaking characteristics of cerebrospinal fluid shunt tubing.

OBJECT: Cerebrospinal fluid (CSF) shunt system malfunction due to silastic tubing fracture necessitates revision surgery in shunt-dependent individuals. The goal of this study was to examine the mechanical stretching and breaking characteristics of new and used CSF shunt tubing catheters to determine if any inherent physical properties predispose the tubing to fracture. METHODS: Fifty-millimeter segments of new and retrieved (used) CSF shunt tubing were stretched to 120 mm in a hydraulic press to determine modulus values (modulus = stress/strain) and to measure permanent tubing deformation imparted by the applied stress and strain. Similar 50-mm tubing segments were also stretched in an electromechanical material testing system until fracture occurred; the force and strain needed to break the tubing was recorded at the time of failure. The results demonstrate that shunt tubing with a greater cross-sectional area requires greater force to fracture, and that catheters become weaker the longer they are implanted. Barium-impregnated shunt tubing, compared with translucent tubing. appears to require less applied stress and strain to break and may fracture more easily in vivo. The variety of modulus values obtained for the new catheters tested indicates that the various companies may be using materials of different quality in tubing manufacture. CONCLUSIONS: A CSF shunt catheter design that incorporates tubing with a greater cross-sectional area may lead to fewer fractures of indwelling catheters and a reduction in shunt revision surgery.

Cerebrospinal Fluid Shunts↗

PubMed1995

A no-touch technique protocol to diminish cerebrospinal fluid shunt infection.

BACKGROUND: Cerebrospinal fluid (CSF) shunts become infected primarily by bacterial organisms indigenous to the patient's skin flora, but bacteria from the operating room environment, hospital, or no obvious source may also infect a shunt. To decrease the incidence of shunt infection, a no-touch technique protocol was developed and utilized in a prospective manner. METHODS: A before-after trial analysis was performed to compare the infection rates between patients who had CSF shunts placed using the no-touch technique protocol versus patients who had surgery without the protocol. Patients were stratified by age, etiology of hydrocephalus, type of shunt surgery, and presence of a contaminated skin wound, namely, tracheostomy, gastrostomy-jejunostomy, colostomy, or halo. The differences in infection rates were analyzed with the Fisher exact test with midpoint value correction, and standard statistical methods were used to calculate the 90% confidence interval odds ratio and number to treat. RESULTS: The no-touch technique protocol resulted in a clinically significant threefold decrease in shunt infection rate from 9.1% to 2.9% (p = 0.058 at 0.10 level, odds ratio 0.305, confidence interval 0.084-1.11), and a near threefold decrease in the infection rate per patient from 11.3% to 3.9% (p = 0.032 at 0.10 level, odds ratio 0.243, confidence interval 0.065-0.906). CONCLUSIONS: The no-touch technique protocol as described herein is a useful method to decrease shunt infection. A larger prospective, randomized, multicenter clinical trial is encouraged to stringently assess the efficacy of the protocol.

Adolescent↗

PubMed1977

Nephritis associated with a diphtheroid-infected cerebrospinal fluid shunt.

Hypocomplementemic proliferative glomerulonephritis occurred during diphtheroid infection of a ventricular decompression shunt for cerebrospinal fluid diversion (cerebrospinal fluid shunt) in a young man. Granular deposits of immunoglobulin M (IgM) and the third component of complement (C3) were found along the glomerular basement membrane. This report provides supportive evidence for immune complex-mediated glomerular injury due to diphtheroid infection in a cerebrospinal fluid shunt.

Adult↗

PubMed2002

Treatment of cerebrospinal fluid shunt infections: a decision analysis.

BACKGROUND: Cerebrospinal fluid shunts transfer cerebrospinal fluid (CSF) from the lateral ventricles in the brain to the peritoneum (ventriculoperitoneal shunt) or the right atrium (ventriculoatrial shunt) via subcutaneous Silastic tubing. As with any implanted foreign body, infection is a serious complication. Although there are several therapeutic modalities currently used for the treatment of shunt infections, controversy remains as to which is best given that there has been only one randomized trial comparing their effectiveness. OBJECTIVE: To determine which treatment modality is most effective by using decision analysis to compare three approaches with regard to cure rate, morbidity and mortality. METHODS: We constructed a decision tree to map out the different treatment modalities and assigned probability values obtained from previously published studies. A utility value was assigned to each treatment outcome, ranging from 0 to 1.0, with a higher score indicating a more favorable outcome. Calculations were performed using Decision Analysis TreeAge computer software. RESULTS: The removal of an infected shunt with establishment of external ventricular drainage or ventricular taps and administration of antibiotics leads to the highest expected value, 0.86. Removal of an infected shunt followed by immediate replacement and administration of antibiotics is less effective, with an expected value of 0.76. The use of antibiotics alone results in the lowest expected value, 0.61. Sensitivity analysis showed the above findings to be robust with respect to clinically relevant changes for the baseline probabilities and utility values. CONCLUSION: A protocol of shunt removal, external ventricular drainage placement or ventricular taps and antibiotics, followed by creation of a new shunt when CSF sterility is achieved, is the most effective method of treatment for CSF shunt infection.

Anti-Bacterial Agents↗

PubMedDate not supplied

Cerebrospinal fluid shunt infections in children.

Infections of cerebrospinal fluid shunts continue to be a substantial source of mortality and morbidity in children with hydrocephalus. Although several therapeutic modalities are currently used for the treatment of shunt infections, there are no clear guidelines for treatment. The purpose of this study was to determine the common pathogens of cerebrospinal fluid shunt infections and evaluate the success of our management. Thirty-five children treated for ventriculoperitoneal shunt infections over the past 9 years were reviewed. The management protocol consisted of the removal of the infected shunt, the application of ventricular taps or reservoir placement, intraventricular antibiotic treatment, and the placement of a new shunt when cerebrospinal fluid sterility was achieved. Four patients were treated with antibiotics alone. Most episodes occurred within 4 months of shunt placement. The most common causative microorganism identified was Staphylococcus epidermidis, followed by S. aureus, and S. warneri. Three patients died from complications of shunt infections, 2 patients had a recurrent shunt infection, while the remaining 29 patients remained free from shunt-related complications. In agreement with the evidence published in the literature, our findings suggest that the above management protocol is effective for the treatment of cerebrospinal fluid shunt infections.

Anti-Bacterial Agents↗

PubMed1995

Epidemiology of cerebrospinal fluid shunting.

The epidemiology of cerebrospinal fluid (CSF) shunting in the United States is not well known; however, with recent national surveys, the prevalence, incidence, and cost of these procedures can be estimated. The prevalence of CSF shunts in the United States appears to be greater than 125,000, though this is likely an underestimate of the true value. There are approximately 69,000 discharges each year with the diagnosis of hydrocephalus. These visits produce nearly 36,000 shunt-related procedures, 33,000 of which involve the placement of a shunt. CSF shunting procedures account for almost US$ 100 million of national health care expenditures each year. Unfortunately, nearly half of these dollars are spent on revision. The rates and costs of CSF shunting underscore the need for continued improvement in both materials and techniques.

Adolescent↗

PubMed1973

Effect of cerebrospinal fluid shunts on intracranial pressure and on cerebrospinal fluid dynamics. 2. A new technique of pressure measurements: results and concepts. 3. A concept of hydrocephalus.

Part 2 describes measurements of intracranial cerebrospinal fluid (CSF) pressure in 18 adult patients with CSF shunts, all pressure measurements being referred to a horizontal plane close to the foramina of Monro. All 18 patients had normal CSF pressure by lumbar puncture; however, in one patient an intracranial pressure of +280 mm was subsequently measured after pneumoencephalography. Twelve patients had pre-shunt CSF pressures measured intracranially: 11 ranged from +20 to +180 mm H(2)O and one was +280 mm H(2)O in the supine position. In the upright posture nine patients had values of -10 to -140 mm H(2)O, while three others were +60, +70, and +280 mm H(2)O. After CSF shunting in these 18 patients the pressures were -30 to +30 mm H(2)O in the supine position and -210 to -370 mm in the upright position. The effect of posture on the siphoning action of these longer shunts in the erect, adult patient is a major uncontrollable variable in maintenance of intracranial pressure after shunting. Other significant variables are reviewed. In Part 3 a concept of the hydrocephalus phenomenon is described. Emphasis is placed on the pressure differential (P(d)) and force differential (F(d)) causing pre-shunt ventricular enlargement and post-shunt ventricular size reduction. The site of P(d), which must be very small and not to be confused with measured ventricular pressure, P, must be at the ventricular wall.

Adult↗

PubMed1987

Bacterial adhesion to cerebrospinal fluid shunts.

Bacterial adherence to cerebrospinal fluid (CSF) shunts was analyzed in vivo and in vitro. Scanning electron micrographs (SEM's) of catheters removed from pediatric patients with shunts infected by Staphylococcus aureus or Klebsiella pneumoniae revealed numerous bacterial cells and microcolonies, leukocytes, and erythrocytes attached to the CSF catheters' inner walls, as well as the existence of surface irregularities, such as fissures, rugosities, and holes. Permeability analyses and SEM's demonstrated that catheters develop physical alterations over the period of implantation. Different bacterial strains presented a different in vitro adherence to CSF shunts, suggesting that this attachment may be affected by specific properties of the outer structures of each strain. The attachment of microbial pathogens to CSF shunts seems to contribute to the persistence of bacterial cells within a catheter and the onset of recurrent shunt infection. This study demonstrated that some bacteria can remain attached within shunts in vitro despite a CSF flow at rates up to 200 times higher than those normally demonstrated in vivo. Furthermore, surface irregularities found throughout this study may help to anchor and hide bacterial microcolonies. Based on these findings, it seems advisable to remove an infected shunt and to replace it with a new one after proper antimicrobial therapy, in order to prevent recurrent infections.

Bacterial Adhesion↗