Commentary

Late complications of ventriculoatrial or ventriculoperitoneal shunts

The selection of patients in whom endoscopic third ventriculostomy (ETV) can be effective remains poorly defined. The ETV success score (ETVSS) and the presence of bowing of the third ventricle have been identified as independent factors for predicting success, each with limitations. The objective of this study is to elaborate a combined predictive model to predict ETV success in a mixed cohort of patients.

Demographic, intraoperative, postoperative, and radiologic variables were analyzed in all ventriculostomies performed consecutively at a single institution from December 2004 to December 2022. Qualitative and quantitative measurements of preoperative, immediate, and late postoperative magnetic resonance imaging were conducted. Univariate analysis and logistic regression models were performed.

118 ETVs were performed in the selected period. Of these procedures, 106 met the inclusion criteria. The overall success rate was 71.7%, with a median follow-up of 3.64 years (interquartile range, 1.06–5.62). The median age was 36.1 years (interquartile range, 11.7–53.5). 35.84% were children (median, 7.81 years). Among the 80 patients with third ventricle bowing, the success rate was 88.8% (P < 0.001). Larger third ventricle dimensions on preoperative mid-sagittal magnetic resonance imaging were associated with increased ETV success. The model with the best receiver operating characteristic curves, with an area under the curve of 0.918 (95% confidence interval, 0.856–0.979) includes sex, ETVSS, presence of complications, and third ventricle bowing.

The presence of bowing of the third ventricle is strongly associated with a higher ETV success rate. However, a combined predictive model that integrates it with the ETVSS is the most appropriate approach for selecting patients for ETV.

The commonest method of elective CSF diversion remains ventriculo-peritoneal shunt (VP shunt). But in some circumstances, VP shunts fail repeatedly or becomes unattractive to the neurosurgeon and this calls for exploration of alternatives. For the index case, Ventriculo-atrial (VA) shunt was favoured and the objective in this report is to share experience gathered there from. Learning points serve to highlight the use of VA shunts as a resort in the drainage of cerebrospinal fluid in the case of repeated failures of peritoneal diversion of CSF and to explain our explain our experience with this index case.

A 54 years old obese woman with previous history of total abdominal hysterectomy was reported. She underwent repeated (three times) revisions of failed peritoneal end of her VP shunt on a background of obstructive hydrocephalus secondary to a posterior fossa tumour (previously excised). Following repeated failure of peritoneal catheter function, she underwent VA shunt and did well.

The decision to place a VA shunt was made after careful deliberations. We discuss the peculiarities in placing a VA shunt. Following placement of a VA shunt, improvement was noted in her clinical condition at one week post op and has been sustained at multiple follow up clinic visits.

VA shunts become an option for cerebrospinal fluid drainage when it becomes unequivocally clear in a multidisciplinary setting that the peritoneal catheter is unlikely to work in view of the unfavourable circumstances of the peritoneal cavity.

Cerebrospinal fluid (CSF) diversion or shunting procedures are the most commonly performed surgery for the treatment of hydrocephalus and are often employed in the management of elevated intracranial pressure due to a variety of diseases. Despite their popularity however, approximately 50% of shunts fail within the first two years, and several revisions are required within the first decade after placement. Ophthalmologists may encounter patients with a CSF shunt to evaluate for concerns of vision loss or diplopia and to determine if papilledema is present. We discuss the neuro-ophthalmic manifestations and evaluation of possible CSF shunt malfunction.

Given recent positive safety evidence, ventriculoatrial (VA) shunt placement may increase in popularity once more. We describe a rare case of Tricuspid regurgitation due to VA shunt catheter tip traversing the valve.

A woman aged 42 years with a preexisting VA shunt was referred to this center with 3 months of orthostatic headache, nausea, and palpitations that occurred while sleeping on her right side. An echocardiogram demonstrates a VA shunt catheter in the right atrium during cardiac diastole, which traversed the tricuspid annular plane during cardiac systole. The echocardiogram revealed mild to moderate tricuspid regurgitation. She had no clinical evidence of cardiac failure or arrhythmia and had normal electrocardiogram findings. The catheter tip appeared to be adhered to the underside of the leaflets or to the chordae tendineae. Pulling the catheter tip back could therefore cause irreversible damage to the tricuspid valve. For this reason, the catheter was not removed, and the patient was referred for close follow-up with cardiologists. A literature review was performed to determine where this rare complication fits into the spectrum of VA shunt distal catheter complications, and what techniques can be done to avoid similar occurrences.

This report reiterates the importance of ensuring the tip is carefully placed within the atrium, under fluoroscopic guidance. Although rare, the described complication is difficult to manage once it has occurred.

There is no consensus concerning the management of adult patients with posterior fossa metastasis–associated obstructive hydrocephalus, especially regarding surgical procedures. A literature review was performed to assess the surgical strategy in the management of patients with metastatic brain tumor.

A literature search was conducted of PubMed in November 2017 to identify all studies concerning brain metastases and obstructive hydrocephalus in English. All studies (except case reports and pediatric studies) between December 1953 and November 2017 that were about posterior fossa metastasis–associated obstructive hydrocephalus in adult patients were eligible. Eligible studies were classified by level of evidence. We assessed epidemiology, clinical and imaging findings, neurosurgical management, and prognosis of adult patients with posterior fossa metastasis–associated obstructive hydrocephalus. We suggest some practical considerations and a management decision tree on behalf of the Neuro-oncology Club of the French Society of Neurosurgery, with evidence-based analysis.

Direct surgical resection could be considered for patients with asymptomatic obstructive hydrocephalus, and endoscopic third ventriculostomy seems to be a reasonable procedure for patients with symptomatic obstructive hydrocephalus. A ventriculoperitoneal or atrial shunt seems to be a valid alternative when patients have a history of central nervous system infection or ventricular hemorrhage, leptomeningeal carcinomatosis, or unfavorable anatomy for an endoscopic third ventriculostomy to be performed.

The Neuro-oncology Club of the French Society of Neurosurgery suggests a prospective assessment of these neurosurgical procedures to compare their safety and efficacy.