OBJECTIVE: Post infective hydrocephalus (PIH) is a type of hydrocephalus which occurs after an infection of the brain or cerebrospinal fluid (CSF). Treatment of PIH requires temporary measures such as external ventricular drain (EVD) and ventriculosubgaleal shunt (VSGS) until CSF becomes clear and ready to implement VP shunt. Limited research has been done to explore the tradeoff between these approaches particularly in pediatric PIH patients. Our study compares the complications, mortality rates, and the cost of used resources of both procedures.
METHODS: A prospective study was conducted for 18 months in which we compared between VSGS and EVD for management of PIH involving 42 randomized cases with 21 patients in group A operated by VSGS and 21 patients in group B operated by EVD.
RESULTS: Our results show a statistically significant difference between both groups in the duration of implementation of VSGS/EVD until resolution of infection occurs. Additionally, a higher rate of pediatric intensive care unit (PICU) admission and a longer length of hospital stay (LOS) were recorded among the EVD group. No statistically significant difference between the number of complications that happened in both despite variations in their forms. Moreover, both groups showed nearly similar mortality rates.
CONCLUSIONS: There is no significant difference in the rate of complications between VSGS and EVD for PIH. Based on that, VSGS emerges as a favorable and cost-effective option for the management of PIH which leads to less economic burden on patients and the country\'s health resources, especially in developing countries.

BACKGROUND: Device-associated CNS infections is a major subgroup of healthcare associated CNS infections. Healthcare-associated ventriculitis or meningitis differs considerably from community-acquired meningitis in its epidemiology, pathogenesis, clinical presentation and management.
OBJECTIVE: This study aimed to identify the infection rates, the associated risk factors, and outcomes of these life-threatening infections.
METHODS: This was a 2-year single center prospective cohort study. Patient\'s clinical data, laboratory parameters, treatment and their outcomes were collected using data collection tool, and device days were collected from the hospital information system (HIS). Patients were categorised using IDSA criteria as contamination or colonisation or infection. Cox regression model was used for multivariate analysis to estimate hazard risk.
RESULTS: A total of 578 CSF diversion catheters were inserted in 472 patients. The average rate for EVD and LD infection were 11.12 and 11.86 per 1000 device days respectively. The average infection rates for VP and LP shunts were 6% and 5.2% per procedure, respectively. The commonest etiological agent causing CSF diversion catheter-related infection (CDRI) was Klebsiella pneumoniae (n = 14, 40%). The risk factors which were independently associated with increased infection risk by cox regression analysis were drain insertion ≥7 days [HR:11.73, p -0.03], posterior approach of EVD insertion (occipital) [HR:9.53, p - 0.01], pre-OP ASA score>3 [HR:8.28, p - 0.013] presence of EVD/LD leak [HR: 17.24, p < 0.0001], male gender [HR:2.05, p-0.05] and presence of associated peri-operative scalp infections [HR:3.531, p-0.005]. Shift to narrow spectrum surgical prophylactic antibiotic [Coefficient: -1.284, p-0.03] and reduction in CSF sampling frequency [Coefficient: -1.741, p-0.02] were found to be negatively associated with CDRI.
CONCLUSIONS: The study demonstrated drain insertion ≥7 days, posterior approach of EVD insertion, presence of EVD/LD leak, male gender and presence of associated peri-operative scalp skin and soft tissue infections were associated with increased risk of infection.

BACKGROUND: Patients with idiopathic normal-pressure hydrocephalus (iNPH) are predisposed to developing dementing disorders. Cerebrospinal fluid (CSF) shunt implantation is a treatment used to improve the motor and cognitive disabilities of these patients; however, its effect on the risk of developing dementing disorders remains unclear. We conducted a population-based propensity-weighted cohort study to investigate whether CSF shunt surgery may reduce the risk of subsequently developing dementia, Alzheimer\'s disease (AD), and vascular dementia in iNPH patients.
METHODS: Patients aged ≥ 60 years who were diagnosed with iNPH (n = 2053) between January 2001 and June 2018 were identified from the Taiwan National Health Insurance Research Database. Various demographic characteristics (age, sex, and monthly income) and clinical data (incidence year, comorbidities, and Charlson comorbidity index) were collected and divided into the shunt surgery group (SSG) and the non-shunt surgery group (NSSG). Stabilized inverse probability of treatment weighting by using the propensity score was performed to achieve a balanced distribution of confounders across the two study groups. The cumulative incidence rate and risk of dementing disorders were estimated during a 16-year follow-up period.
RESULTS: After weighting, the data of 375.0 patients in SSG and 1677.4 patients in NSSG were analyzed. Kaplan-Meier curve analysis indicated that the cumulative incidence rate of AD (p = 0.009), but not dementia (p = 0.241) and vascular dementia (p = 0.761), in SSG was significantly lower than that in NSSG over the 16-year follow-up period. Cox proportional hazards regression analysis revealed that SSG had a reduced hazard ratio (HR) for developing AD [HR (95% CI) 0.17 (0.04-0.69)], but not for dementia [HR (95% CI) 0.83 (0.61-1.12)] and vascular dementia [HR (95% CI) 1.18 (0.44-3.16)], compared with NSSG. Further Fine-Gray hazard regression analysis with death as a competing event demonstrated that SSG had a reduced subdistribution HR (sHR) for developing dementia [sHR (95% CI) 0.74 (0.55-0.99)] and AD [sHR (95% CI) 0.15 (0.04-0.61)], but not for vascular dementia [sHR (95% CI) 1.07 (0.40-2.86)].
CONCLUSIONS: CSF shunt surgery is associated with reduced risks of the subsequent development of dementia and AD in iNPH patients. Our findings may provide valuable information for assessing the benefit-to-risk profile of CSF shunt surgery.

The ventriculoatrial (VA) shunt is a surgical intervention used to manage hydrocephalus, although it is less often utilized compared to the ventriculoperitoneal (VP) shunt or endoscopic third ventriculostomy. Placement of the distal catheter typically involves the utilization of either the common facial vein (CFV) or the internal jugular vein (IJV), 2 frequently employed options for venous access. This study aims to determine whether there is a statistically significant difference between the long-term patency (2 years) of the distal end of the VA shunt of these 2 options.
A retrospective cohort analysis was conducted of patients who received VA shunt surgeries with the employment of the CFV or IJV as access veins at Rajavithi Hospital in Thailand between January 2015 and December 2020. The analysis focused on long-term patency and potential complications.
The study comprised a total of 42 participants. Twenty-six (61.9%) individuals underwent ventriculoatrial (VA) shunt surgery via the CFV, while the other 16 (38.1%) underwent the same procedure using the IJV. Neither of the 2 groups required shunt revision due to distal catheter malfunction. Most cases exhibited no significant complications apart from a single instance of shunt system infection.
In VA shunt surgery, both the CFV and IJV can be used as venous access sites for the right atrium because there is no discernible difference between their complications or long-term patency. Anatomical considerations, patient-specific characteristics, and the surgeon\'s preference should all be considered when choosing the venous access location for the placement of a VA shunt.

Inserting cerebrospinal fluid diversion devices such as external ventricular drains (EVDs) and ventriculoperitoneal shunts (VPSs) is a critical procedure. Unfortunately, complications such as catheter misplacement, dislocation, or infection can occur. Various surgical strategies aim to reduce these risks. One recent innovation is the \"catheter-locking device-assisted\" technique for EVD surgery. In this study, we examined its application in a larger group of cases encompassing both EVDs and VPSs over a 30-month period, with a focus on these complications.
All adult patients who underwent a shunt procedure for noninfectious hydrocephalus at our institution from January 2021 to June 2023 were reviewed. We compared complications between those treated with the \"standard\" technique (subgroup A) and those managed with the \"catheter-locking device-assisted\" approach (subgroup B).
In the EVD surgical group (initial procedures, n = 161), 6 patients (3.7%) required reoperation owing to the catheter misplacement caused by inadvertent migration of the ventricular catheter within the operating room (\"early\" migration), while 11 patients (6.8%) experienced unintentional postoperative dislodgement (\"delayed\" migration). Seven patients (4.3%) developed an EVD-related infection after an average duration of 7.4 days. None of these complications were observed in subgroup B patients (P < 0.05). Among VPS patients (n = 137), 4 (2.9%), all in subgroup A, required reoperation due to intraoperative migration of the catheter (P = 0.121); no other complications were identified.
The \"catheter-locking device-assisted\" technique may significantly decrease the occurrence of the most common EVD complications and can also prove beneficial in VPS surgery. However, further investigation is necessary.

OBJECTIVE: MRI volumetry could be used as an alternative to invasive tests of shunt function. In this study, the authors aimed to assess the difference in ventricular volume (VV) before and after surgery and at different performance levels (PLs) of the shunt.
METHODS: This study was a randomized, double-blind trial with a crossover design. The study sample consisted of 36 patients (25 men, 11 women) with a median age of 76 years. All patients had idiopathic normal pressure hydrocephalus (iNPH) and received a Strata shunt at the regional hospital in Östersund, Sweden, with an initial PL of 1.5. Participants underwent MRI with volumetric sequences before surgery and four times postoperatively: at 1 month before randomization to either PL 1.0 (n = 15) or 2.5 (n = 17); at 2 months before crossover to PL 2.5 or 1.0; at 3 months before lowering the PL to 0.5; and finally, at 3 months and 1 day after surgery before resetting the PL to 1.5. VV was measured semiautomatically using quantitative MRI. Both the patient and the examiner of clinical tests and volumetry were blinded to the PL.
RESULTS: VV changed significantly between the presurgical level (median 129 ml) and the different shunt settings, i.e., PL 1.0 (median 115 ml), 1.5 (median 120 ml), and 2.5 (median 128 ml; p < 0.001). A unidirectional change in VV was observed for all participants between PL 1.0 and PL 2.5 (median 12 ml, range 2.1-40.7 ml, p < 0.001). No significant change was noted in VV after 24 hours at PL 0.5. Eight participants had asymptomatic subdural effusions at PL 1.0.
CONCLUSIONS: The consistent decrease in VV after shunt surgery and between PL 2.5 and 1.0 supports the idea that MRI volumetry could be a noninvasive method for evaluating shunt function in iNPH, preventing unnecessary shunt revisions. However, further studies on retest variability of VV as well as verification against advanced testing of shunt function are needed before a clinical implementation of this method can be performed. Clinical trial registration no.: NCT04599153 (ClinicalTrials.gov).

OBJECTIVE: Cerebrospinal fluid (CSF) white blood cell (WBC) count, neutrophil percentage, protein concentration, and glucose level are typically measured at diagnosis and serially during the treatment of CSF shunt infections. The objective of this retrospective cohort study was to describe the longitudinal profile of CSF parameters in children with CSF shunt infections and assess their association with treatment and outcome.
METHODS: Participants were children treated at 11 tertiary pediatric hospitals in Canada and the United States for CSF shunt infection, from July 1, 2013, through June 30, 2019, with hardware removal, external ventricular drain placement, intravenous antibiotics, and subsequent permanent shunt reinsertion. The relationship between CSF parameters and a complicated course (a composite outcome representing children with at least one of the following: contiguous soft-tissue infection, worsening hydrocephalus, CSF leak, intracranial bleed, brain abscess, venous thrombosis, reinfection after insertion of the new shunt, other complication, ICU admission, or death) was analyzed.
RESULTS: A total of 109 children (median age 2.8 years, 44% female) were included in this study. CSF pleocytosis, elevated protein, and hypoglycorrhachia had sensitivities of 69%, 47%, and 38% for the diagnosis of culture-confirmed CSF shunt infection, respectively. The longitudinal profile of the neutrophil percentage followed a monotonic trend, decreasing by 1.5% (95% CI 1.0%-2.0%, p < 0.0001) per day over the course of treatment. The initial WBC count differed significantly between pathogens (p = 0.011), but the proportion of neutrophils, protein concentration, and glucose level did not, and was lowest with Cutibacterium acnes. The duration of antibiotic treatment and the time to shunt reinsertion were longer in patients with a higher initial neutrophil percentage. Fifty-eight patients (53%) had one or more complications during their admission. A neutrophil percentage > 44% (Youden index) in the initial CSF sample was associated with a 1.8-fold (95% CI 1.2- to 2.8-fold) higher relative risk of a complicated course. In a random-intercept, random-slope linear mixed-effects model, the longitudinal neutrophil trajectory differed significantly between patients with and without complications (p = 0.030).
CONCLUSIONS: A higher proportion of neutrophils in the CSF at diagnosis was associated with a complicated clinical course. Other CSF parameters were associated with treatment and outcome; however, wide variability in values may limit their clinical utility.

BACKGROUND: Slit ventricle syndrome (SVS) remains a challenging problem in the early-shunted paediatric population. Various surgical and non-surgical treatments have been devised for this condition. However, there is currently no gold standard for its optimal management. Among various treatment modalities, subtemporal decompression (STD) is often performed as a last resort. We present our experience of STD in paediatric patients with SVS in whom initial treatment with programmable valves and anti-syphon device were not successful.
METHODS: This is a single-centre retrospective observational study and survival analysis. Patients who underwent STD for SVS were included. Pre- and post-operative imaging data and clinical outcomes were collected.
RESULTS: There were 20 patients (12 M, 8 F) with a mean age of 9 years (SD: 4) at first STD. 90% (n = 18) of patients had multiple shunt revisions pre-STD. At first STD, 70% (n = 14) and 30% (n = 6) of patients had unilateral or bilateral STD, respectively. STD led to a reduction in the frequency of shunt revisions in 60% (n = 12) of patients. The median time required before further STD, shunt surgery, or cranial vault surgery was 14 months. The median time before a further STD was required (either revision or contralateral side) was 89 months. At a median follow-up of 66.5 months (range: 1-159), 65% (n = 13) of patients had improvement in symptoms.
CONCLUSIONS: A large proportion of patients with persistent SVS symptoms, refractory to multiple shunt revisions, benefitted from STD in combination with shunt optimization. It was also safe and well-tolerated. Therefore, in patients who have multiple failed shunts, STD may reduce the morbidity associated with further shunt revisions and can significantly improve symptomatology.

The quantity of ultra-high field MRI neuroimaging studies has rapidly increased. This study tests function, safety, and image artifacts of two frequently implanted programmable ventriculo-peritoneal (VP) shunt valves in a 7T MRI system.
All tests were performed using a whole-body 7T MRI system. Three proGAV 2.0 and 3 CODMAN CERTAS® Plus programmable VP-shunt valves were tested in three steps. 1) Deflection angle tests close to the bore opening at the location of a static magnetic field gradient of 3-5 T/m. 2) Valves were fixed on a spherical phantom in 3 positions (a. lateral, b. cranial, c. cranial with 22.5° tilt anteriorly) and assessed for keeping the programmed pressure setting and reprogrammability. 3) Valves were fixed on the phantom and positioned lateral in a radiofrequency head coil. MRI scans were performed for both models, including MPRAGE, GRE and SE sequences.
Deflection angles were moderate (13°, 14°, 13°) for the proGAV valves and close to critical (43°, 43°, 41°) for the CODMAN valves at the test location. Taking a scaling factor of 2-3 for the maximum spatial magnetic field gradient accessible to a patient within the magnet bore into account renders both valves MR unsafe regarding ferromagnetic attraction. The proGAV valves kept the pressure settings in all positions and were reprogrammable in positions a. and b. In position c., reprogrammability was lost. The CODMAN valves changed their pressure setting and reprogrammability was lost in all positions. MR image signal homogeneity was unaltered in the phantom center, artifacts limit the assessability of structures in close vicinity to the valves.
Both tested programmable VP-shunt valves are MR unsafe for 7T systems. Novel programming mechanisms using permanent magnets with sufficient magnetic coercivity or magnet-free mechanisms may allow the development of programmable VP-shunt valves that are conditional for 7T MR systems.

Factors associated with external ventricular catheter tract hemorrhage (CTH) are well studied; whether CTH adversely influence outcomes after intracerebral hemorrhage (sICH), however, is poorly understood. We therefore sought to evaluate the association between CTH and sICH outcomes.
We performed a post hoc analysis of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage trial. The exposure was CTH and evaluated on serial computed tomography scans between admission and randomization (approximately 72 hours). The primary outcomes were a composite of death or major disability (modified Rankin Score >3) and mortality alone, both assessed at 6 months. Secondary outcomes were functional outcomes at 30 days, permanent cerebrospinal fluid (CSF) shunt placement, any infection, and ventriculitis. We performed logistic regression adjusted for demographics, comorbidities, sICH characteristics, and treatment assignment, for all analyses.
Of the 500 patients included, the mean age was 59 (SD, ±11) years and 222 (44%) were female. CTH occurred in 112 (22.4%) patients and was more common in minority patients, those on prior antiplatelet therapy, and patients who had more than 1 external ventricular drain placed. The end of treatment intraventricular hemorrhage volume was higher among patients with CTH (11.7 vs 7.9 mL, P = .01), but there were no differences in other sICH characteristics or the total duration of external ventricular drain. In multivariable regression models, CTH was not associated with death or major disability (odds ratio, 0.7; 95% CI: 0.4-1.2) or death alone (odds ratio, 0.8; 95% CI, 0.5-1.4). There were no relationships between CTH and secondary outcomes including 30-day functional outcomes, permanent CSF shunt placement, any infection, or ventriculitis.
Among patients with sICH and large intraventricular hemorrhage, CTH was not associated with poor sICH outcomes, permanent CSF shunt placement, or infections. A more detailed cognitive evaluation is needed to inform about the role of CTH in sICH prognosis.