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Yield of early postoperative computed tomography after frontal ventriculoperitoneal shunt placement.

ABSTRACT: Despite being widely used, ventriculoperitoneal (VP) shunt placement is a procedure often associated with complications and revision surgeries. Many neurosurgical centers routinely perform early postoperative cranial computer tomography (CT) to detect postoperative complications (e.g., catheter malposition, postoperative bleed, over-drainage). Because guidelines are lacking, our study aimed to evaluate the yield of early routine postoperative CT after shunt placement for adult hydrocephalus. We retrospectively reviewed 173 patients who underwent frontal VP shunting for various neurosurgical conditions. Radiological outcomes were proximal catheter malposition, and ventricular width in preoperative and postoperative imaging. Clinical outcomes included postoperative neurological outcome, revision surgery because of catheter malposition or other causes, mortality, and finally surgical, non-surgical, and overall morbidity. In only 3 (1.7%) patients did the early routine postoperative CT lead to revision surgery. Diagnostic ratios for CT finding 1 asymptomatic patient who eventually underwent revision surgery per total number to scan were 1:58 for shunt malposition, 1:86 for hygroma, and 1:173 for a cranial bleed. Five (2.9%) patients with clinically asymptomatic shunt malposition or hygroma underwent intervention based on early postoperative CT (diagnostic ratio 1:25). Shunt malposition occurred in no patient with normal pressure hydrocephalus and 2 (40%) patients with stroke. Lower preoperative Evans' Index was a statistically significant predictor for high-grade shunt malposition. We found a rather low yield for early routine postoperative cranial CT after frontal VP-shunt placement. Therefore, careful selection of patients who might benefit, considering the underlying disease and preoperative radiological findings, could reduce unnecessary costs and exposure to radiation.

SUBMITTER: Kamenova M

PROVIDER: S-EPMC6007904 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Yield of early postoperative computed tomography after frontal ventriculoperitoneal shunt placement.

Kamenova Maria M Rychen Jonathan J Guzman Raphael R Mariani Luigi L Soleman Jehuda J

PloS one 20180619 6

Despite being widely used, ventriculoperitoneal (VP) shunt placement is a procedure often associated with complications and revision surgeries. Many neurosurgical centers routinely perform early postoperative cranial computer tomography (CT) to detect postoperative complications (e.g., catheter malposition, postoperative bleed, over-drainage). Because guidelines are lacking, our study aimed to evaluate the yield of early routine postoperative CT after shunt placement for adult hydrocephalus. We ...[more]

PMID: 29920522

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Project description:Background:Postoperative communicating hydrocephalus has been described in the literature commonly associated with treatment of ruptured intracranial aneurysms; however, it is also reported to occur following other intracranial interventions such as meningioma resection and decompressive hemicraniectomy. In 2011, Burkhardt et al. reported the incidence of postoperative hydrocephalus following skull base meningioma resection was twice as high as resection of meningiomas in other regions.[1] They found that age and increased length of surgery were associated with higher rates of postoperative hydrocephalus. Our patient, a 76-year-old man, initially presented with the left-hand paresthesias and numbness before the revelation of a large sphenoid planum meningioma on workup imaging. He underwent surgical resection due to developing cranial nerve deficits and personality changes in an extensive procedure that required approximately 8 h to complete. His postoperative course, given the factors above, included the development of hydrocephalus. Case Description:He was taken to the operating room for ventriculoperitoneal shunt placement, as displayed in this video case report, which highlights our surgical and sterile techniques, intraoperative ultrasound to ensure appropriate ventricular placement, and a single-port laparoscopic technique for direct visualization of placement of the abdominal catheter. After shunt placement, his course was complicated by a small tract hemorrhage, which resolved without further treatment. He was observed to have an improvement in mental function that occurred over the following 2-3 days before being discharged to an outpatient rehabilitation facility for continued care. Conclusion:Ventriculoperitoneal shunt placement is an effective and safe procedure for the treatment of postoperative communicating hydrocephalus when performed with appropriate techniques as displayed in the associated video case report. The patient gave informed consent for surgery and video recording. Institutional Review Board approval was deemed unnecessary.

Project description:Treatment for idiopathic normal pressure hydrocephalus (iNPH) continues to develop. Although ventriculoperitoneal shunt surgery has a long history and is one of the most established neurosurgeries, in the 1970s, the improvement rate of iNPH triad symptoms was poor and the risks related to shunt implantation were high. This led experts to question the surgical indication for iNPH and, over the next 20 years, cerebrospinal fluid (CSF) shunt surgery for iNPH fell out of favor and was rarely performed. However, the development of programmable-pressure shunt valve devices has reduced the major complications associated with the CSF drainage volume and appears to have increased shunt effectiveness. In addition, the development of support devices for the placement of ventricular catheters including preoperative virtual simulation and navigation systems has increased the certainty of ventriculoperitoneal shunt surgery. Secure shunt implantation is the most important prognostic indicator, but ensuring optimal initial valve pressure is also important. Since over-drainage is most likely to occur in the month after shunting, it is generally believed that a high initial setting of shunt valve pressure is the safest option. However, this does not always result in sufficient improvement of the symptoms in the early period after shunting. In fact, evidence suggests that setting the optimal valve pressure early after shunting may cause symptoms to improve earlier. This leads to improved quality of life and better long-term independent living expectations. However, in iNPH patients, the remaining symptoms may worsen again after several years, even when there is initial improvement due to setting the optimal valve pressure early after shunting. Because of the possibility of insufficient CSF drainage, the valve pressure should be reduced by one step (2-4 cmH2O) after 6 months to a year after shunting to maximize symptom improvement. After the valve pressure is reduced, a head CT scan is advised a month later.

Dataset Information

Yield of early postoperative computed tomography after frontal ventriculoperitoneal shunt placement.

Publications

Yield of early postoperative computed tomography after frontal ventriculoperitoneal shunt placement.

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