Basicranial changes were studied in a sample of 29 shunt-treated hydrocephalics, aged 7 to 18 years, by analyzing differences in angular relationships between structures seen on roentgenologic cephalograms taken at intervals of about 2 years following initial examination. In addition, the natural head position was recorded in 24 subjects at a follow-up examination. The cranial base among the boys showed increased flexure during the follow-up period. This finding was reflected in a decrease in the angle between the sphenoidal and clival planes and that of the nasion-sella-basion. Head posture, calculated in terms of the craniovertical and cervicohorizontal angles, was more forwardly flexed in the shunt-treated subjects than in the corresponding controls.
The distribution of shunt complications is analyzed in a series of 226 children and infants out of a total of 978 shunt operations performed between the years 1965 and 1989. The rate of shunt infections and obstructions has decreased significantly during the last ten years while the rate of CSF overdrainage complications has increased. A policy of active, elective shunt revisions has led to a reduction in the total rate of shunt revisions required. As only minor changes in the shunts available and used have taken place during the period converted, it is concluded that the main reason for the changing panorama of shunt revisions lies in improved neuroimaging and a better knowledge of complying with shunt complications.
Results of 884 first-time shunts inserted in the time period from 1958 to 1989 are retrospectively evaluated, 1) to perform a durability analysis of a shunt based on Kaplan-Meyer method, 2) to compare the rate of revision for ventriculo-atrial (VA) and ventriculo-peritoneal (VP) shunts, 3) to compare the durability of a VA shunt with a VP shunt and 4) to do a stratified durability analysis comparing the VA and VP shunts in relation to the following background variables: shunt type, time period and age of the patient. Furthermore the specific complications related to VA and VP shunts are identified based on findings in the literature. Overall one-year shunt durability is 57% and five-year shunt durability is 37%. The median shunt durability is 1.68 years. Revision rate is 51% for VA shunts and 38.5% for VP (p
The degree and direction of craniofacial asymmetry in the frontal plane was studied in a sample of 26 shunt-treated hydrocephalic children aged 5 to 18 years. Thirteen of the children had the regulating shunt fixed on the right side of the head and 13 on the left. The shunt had usually been inserted during the first years of life. An age- and sex-matched group of healthy school children and students served as controls for cephalometric assessment by means of linear and angular measurements. Considerable craniofacial asymmetry was found in the shunt-treated hydrocephalic children, the direction of asymmetry being related to the laterality of the regulating shunt device. The most marked asymmetric changes were recorded in the maxillary and mandibular regions, probably due to the adaptive nature of these regions.
In hydrocephalic children, ventriculo-peritoneal shunting is the preferred treatment with few complications. However, an obviously non-infectious peritoneal reaction to the cerebrospinal fluid (CSF) may occasionally lead to shunt malfunction. In eight hydrocephalic children, shunt malfunction with distal catheter complication was found with abdominal pseudocyst formation in seven cases and accumulation of the CSF in one. All children had a normal CSF cell count and glucose concentration, and white cell count, and C-reactive protein in peripheral blood were normal. No CSF infection could be detected despite prolonged aerobic and anaerobic cultures. After initial externalisation of the shunt and subsequent routine administration of antibiotics because infection initially was suspected, ventriculo-peritoneal shunting was attempted one to three times with identical failure before successful conversion to a ventriculo-atrial system. At laparotomy the peritoneum and intestinal serosa were hyperaemic and oedematous in all patients, five of whom also had pseudocysts and two of whom also had intra-abdominal adhesions. Four children had a revision 6-24 years after the ventriculo-atrial conversion due to short atrial catheter with distal obstruction. In three of them, the distal catheter was successfully replaced into the peritoneal cavity. The fourth child, however, developed an infectious abdominal pseudocyst with adhesions due to a then undetected Propionibacterium acnes infection. After externalisation and antibiotics, a new ventriculo-atrial shunt was inserted. At follow-up between 5 months to nearly 6 years later, the three children with peritoneal catheters did not show any signs of shunt malfunction or abdominal problems. Thus hydrocephalic children may develop shunt malfunction with distal catheter obstruction due to a still unexplained, transient, non-infectious peritoneal reaction leading to abdominal pseudocyst formation or accumulation of CSF. In some children, however, it may later be possible to replace the distal catheter into the peritoneal cavity, if no infection is involved.
Based on a retrospective study in which a total of 541 Codman Hakim Programmable Valves (CHPV) were implanted in 477 patients over a 6-year period, this cost analysis was performed. By using a valve with an adjustable opening pressure, valve exchange to alter the opening pressure and surgical evacuation of subdural haematomas and hygromas can be avoided. Dividing the added cost for using the CHPV by the cost of implanting a non-programmable Hakim valve results in 105.8 valve exchanges, which would have had to be avoided to break even financially. On 107 occasions a valve was adjusted by a magnitude of 50 mmH2O or more. This, if an adjustment of that magnitude is said to correspond to a valve exchange, is sufficient to break even. The analysis suggests that the extra cost of the valve is outweighed by the ability to adjust the opening pressure setting non-invasively.
Overdrainage of the cerebrospinal fluid (CSF) and collapse of the ventricles, slit ventricles (SLV), can cause clinical symptoms and result in the slit ventricle syndrome (SLVS). The EEG changes and the frequency and type of epilepsy in patients with SLV was analysed from a material of 113 shunt-treated hydrocephalic children. During the follow-up time (mean 8.9 years), 63 patients (56%) had developed SLV. The age at initial shunting was significantly lower (1.2 years) in patients who developed SLV than for those who did not (2.7 years). After initial shunting generalized spike and sharp wave activity (SWA) developed more frequently in patients who developed SLV (81%) than in those who did not (54%). Severe generalized SWA developed almost entirely in patients in the SLV group. This severe generalized SWA disappeared from the EEG in patients after treatment of the SLVS. Epileptic seizures appeared after initial shunting in 44% of patients in the SLV group but in only 6% of the non-SLV group. Treatment of the SLVS decreased the frequency of epilepsy to a level corresponding with the non-SLV group. Repeated EEG evaluation of shunt-treated hydrocephalic children is a valuable aid in follow-up. If EEG abnormality appears after initial shunting, especially SWA, shunt malfunction and overdrainage of the CSF should be suspected.
OBJECT: The object of this study was to analyze the outcome of endoscopic third ventriculostomy (ETV) in patients under 2 years of age and investigate factors related to ETV success or failure in this patient population. METHODS: The authors reviewed their experience in using endoscopic third ventriculostomy (ETV) in the treatment of 41 hydrocephalus patients younger than 2 years. The mean duration of follow-up was 45 months. The relationship between ETV efficacy and the following variables was analyzed: cause of hydrocephalus, level of CSF occlusion, primary versus secondary ETV, type of surgical procedure, head circumference, patient age at ETV, patient age at first manifestation of hydrocephalus, and anatomical features of the ventricle. Success of ETV was assessed based on the results of neurological examination and postoperative imaging during the follow-up period. RESULTS: The authors performed 32 primary ETVs and 10 secondary ETVs (ETV after hydrocephalus surgery) in 41 patients (a second ETV was performed in 1 patient). The success rates of primary and secondary ETV were 75.8 and 55.6%, respectively (no significant difference, p = 0.15). The ETV was clinically and radiologically successful in 30 (71.4%) of 42 procedures during a mean (+/- SD) follow-up period of 45.0 +/- 4.8 months (range 12-127 months). A negative relationship was found between success of ETV and the thickness of the floor of the third ventricle (the most effective procedures were those in which the floor of the ventricle was thinnest [p
The incidence of slit ventricles of shunt treated hydrocephalic children was evaluated in a follow up study of 141 patients. Slit like ventricles on computer tomography was seen in 75 patients (53%). 52 patients (37%) suffered from clinical symptoms corresponding with overdrainage of cerebrospinal fluid. Those 52 patients with the "Slit Ventricle Syndrome" (SLVS) were treated by changing the valve to one with a higher opening pressure and/or adding an antisiphon device (ASD) to the shunt. 22 patients, initially treated by changing the opening pressure of the valve, needed the ASD later. Altogether 74 episodes of the SLVS were treated. The ASD proved reliable for the management of the SLVS. Normalization of ventricular size occurred in 54% of patients. whereas only in 15% treated without the ASD. Reduction of paroxysmal activity on EEG was seen in 70% of patients treated with the ASD, whereas only in 23% of patients treated without the ASD. Clinical relief of symptoms occurred in every patient, and ventricular catheter obstructions could be avoided, even if the ventricular size remained slit-like on CT.