UNASSIGNED: Significant neurologic morbidity is caused by pediatric cerebrospinal fluid (CSF) shunt infections. The underlying mechanisms leading to impaired school performance and increased risk of seizures are unknown, however, a better understanding of these mechanisms may allow us to temper their consequences. Recent evidence has demonstrated important roles for complement proteins in neurodevelopment and neuroinflammation.
UNASSIGNED: We examined complement activation throughout Staphylococcus epidermidis (S. epidermidis) central nervous system (CNS) catheter infection. In addition, based on accumulating evidence that C3 plays a role in synaptic pruning in other neuroinflammatory states we determined if C3 and downstream C5 led to alterations in synaptic protein levels. Using our murine model of S. epidermidis catheter infection we quantified levels of the complement components C1q, Factor B, MASP2, C3, and C5 over the course of infection along with bacterial burdens.
UNASSIGNED: We found that MASP2 predominated early in catheter infection, but that Factor B was elevated at intermediate time points. Unexpectedly C1q was elevated at late timepoints when bacterial burdens were low or undetectable. Based on these findings and the wealth of information regarding the emerging roles of C1q in the CNS, this suggests functions beyond pathogen elimination during S. epidermidis CNS catheter infection. To identify if C3 impacted synaptic protein levels we performed synaptosome isolation and quantified levels of VGLUT1 and PSD95 as well as pre-, post- and total synaptic puncta in cortical layer V of C3 knockout (KO) and wild type mice. We also used C5 KO and wild type mice to determine if there was any difference in pre-, post- and total synaptic puncta.
UNASSIGNED: Neither C3 nor C5 impacted synaptic protein abundance. These findings suggest that chronic elevations in C1q in the brain that persist once CNS catheter infection has resolved may be modulating disease sequalae.

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.

Neuraxial anesthesia in patients with cerebrospinal fluid (CSF) shunt devices has traditionally been associated with a high risk of complications. In order to gather all available evidence, a structured search was conducted to include published studies involving users of these devices, undergoing any form of neuraxial technique for obstetric or surgical procedures unrelated to them. Effectiveness of the technique and perioperative complications were assessed. Only case series and case reports (n = 72) were identified. One patient was found to have insufficient anesthetic coverage, necessitating a modification of the technique, and another one had an intraoperative complication which compromised the subject\'s safety. No infection events or postoperative device dysfunction related to the anesthetic method were described. The evidence found is scarce and of low quality, preventing the establishment of significant conclusions. Nevertheless, patients may obtain benefit from an individualized evaluation.

Many physicians, particularly neurosurgeons, face malpractice claims during their career. The aim of this paper is to identify which factors increase the risk of litigation and influence legal outcomes relating to cerebrospinal fluid shunt management. Westlaw, an online legal database, was used to identify all medico-legal cases pertaining to cerebrospinal fluid shunts. Information regarding plaintiff demographics, defendant specialties, reasons for litigation, and trial outcomes were analysed. Thirty-six cases met criteria for inclusion. Most cases returned a defence verdict (44.4%), with delayed treatment or failure to appropriately treat patients with shunts the most common reason for litigation (66.7%). The average plaintiff verdict payout was $4,888,136.75 and average settlement $1,362,307.69. Delay or failure to treat resulted in the largest average payouts for plaintiff verdicts and settlements ($5,329,299.14 and $1,531,500.00, respectively).

BACKGROUND: Over the recent decades, the number of different manufacturers and models of cerebrospinal fluid shunt valves constantly increased. Proper identification of shunt valves on X-ray images is crucial to neurosurgeons and radiologists to derive further details of a specific shunt valve, such as opening pressure settings and MR scanning conditions. The main aim of this study is to evaluate the feasibility of an AI-assisted shunt valve detection system.
METHODS: The dataset used contains 2070 anonymized images of ten different, commonly used shunt valve types. All images were acquired from skull X-rays or scout CT-images. The images were randomly split into a 80% training and 20% validation set. An implementation in Python with the FastAi library was used to train a convolutional neural network (CNN) using a transfer learning method on a pre-trained model.
RESULTS: Overall, our model achieved an F1-score of 99% to predict the correct shunt valve model. F1-scores for individual shunt valves ranged from 92% for the Sophysa Sophy Mini SM8 to 100% for several other models.
CONCLUSIONS: This technology has the potential to automatically detect different shunt valve models in a fast and precise way and may facilitate the identification of an unknown shunt valve on X-ray or CT scout images. The deep learning model we developed could be integrated into PACS systems or standalone mobile applications to enhance clinical workflows.

UNASSIGNED: The development of persistent hydrocephalus in patients after spontaneous intracerebral hemorrhage (ICH) is still poorly understood, and many variables predicting the need for a cerebrospinal fluid (CSF)-shunt have been described in the literature with varying results. The aim of this study is to find predictive factors for shunt dependency.
UNASSIGNED: We performed a retrospective, single-center study of 99 neurosurgically treated patients with spontaneous ICH. Variables, including age, Glasgow Coma Scale (GCS), intraventricular hemorrhage (IVH), location of hemorrhage, acute hydrocephalus, and volumetric analysis of IVH, ICH, and intraventricular CSF were compared between patients with and without CSF-shunt implantation. Furthermore, receiver operating characteristics (ROC) for ICH, IVH, and intraventricular CSF volume parameters were calculated.
UNASSIGNED: CSF-shunt implantation was performed significantly more often in patients after thalamic (p = 0.03) and cerebellar ICH (p = 0.04). Moreover, a lower ratio between the total hemorrhage volume and intraventricular CSF volume (p = 0.007), a higher IVH distribution in the third ventricle, and an acute hydrocephalus (p < 0.001) with an increased intraventricular CSF volume (p < 0.001) were associated with shunt dependency. Our ROC model demonstrated a sensitivity of 82% and a specificity of 65% to predict the necessity for a shunt at a cutoff value of 1.9 with an AUC of 0.835.
UNASSIGNED: Volumetric analysis of ICH, IVH, and intraventricular CSF may improve the prediction of CSF shunt implantation in patients with spontaneous ICH.

Ventriculitis is associated with cerebrospinal fluid (CSF) shunts, and rare microorganisms associated with infection include vancomycin-resistant Enterococcus (VRE) faecium and Acinetobacter baumannii. Both organisms are known to cause nosocomial infections, and the emergence of multidrug-resistant (MDR) strains presents a treatment challenge. There is a lack of consensus on antimicrobial agent selection for ventriculitis involving VRE faecium or MDR A. baumannii, which are life-threatening conditions. We present a case of a 59-year-old male presenting with CSF catheter-associated VRE faecium ventriculitis and MDR A. baumannii pneumonia who subsequently developed a nosocomial MDR A. baumannii ventriculitis. Both instances of ventriculitis were successfully treated with combination antibiotic therapy. VRE faecium ventriculitis was successfully treated with linezolid and intrathecal daptomycin. While daptomycin is not approved for Enterococcal infections, the synergistic effect of daptomycin in combination with linezolid proved effective. Although the MDR A. baumannii pneumonia was not cured with cefiderocol monotherapy, the MDR A. baumannii ventriculitis was successfully treated with combination therapy including cefiderocol, ampicillin/sulbactam, and intrathecal colistin. This highlights life-saving combination antibiotic therapies for ventriculitis caused by multiple rare and drug-resistant microorganisms.

As neurosurgery has advanced technologically, more and more neurosurgical implants are being employed on an aging patient population with several comorbidities. As a result, there is a steady increase in the frequency of infections linked to neurosurgical implants, which causes serious morbidity and mortality as well as abnormalities of the skull and inadequate brain protection. We discuss infections linked to internal and external ventricular and lumbar cerebrospinal fluid drainages, neurostimulators, craniotomies, and cranioplasty in this article. Biofilms, which are challenging to remove, are involved in all implant-associated illnesses. It takes a small quantity of microorganisms to create a biofilm on the implant surface. Skin flora bacteria are implicated in the majority of illnesses. Microorganisms that cause disruptions in wound healing make their way to the implant either during or right after surgery. In about two thirds of patients, implant-associated infections manifest early (within the first month after surgery), whereas the remaining infections present later as a result of low-grade infections or by direct extension from adjacent infections (per continuitatem) to the implants due to soft tissue damage. Except for ventriculo-atrial cerebrospinal fluid shunts, neurosurgical implants are rarely infected by the haematogenous route. This research examines established and clinically validated principles that are applicable to a range of surgical specialties using implants to treat biofilm-associated infections in orthopaedic and trauma cases. Nevertheless, there is little evidence and no evaluation in sizable patient populations to support the success of this extrapolation to neurosurgical patients. An optimal microbiological diagnostic, which includes sonicating removed implants and extending culture incubation times, is necessary for a positive result. Additionally, a strategy combining surgical and antibiotic therapy is needed. Surgical procedures involve a suitable debridement along with implant replacement or exchange, contingent on the biofilm\'s age and the state of the soft tissue. A protracted biofilm-active therapy is a component of antimicrobial treatment, usually lasting 4-12 weeks. This idea is appealing because it allows implants to be changed or kept in place for a single surgical procedure in a subset of patients. This not only enhances quality of life but also lowers morbidity because each additional neurosurgical procedure increases the risk of secondary complications like intracerebral bleeding or ischemia.

OBJECTIVE: Knowledge-based tools used to standardize perioperative care, such as the shunt infection prevention protocol of the Hydrocephalus Clinical Research Network (HCRN), have demonstrated their ability to reduce surgeon-based and center-based variations in outcomes and improve patient care. The mere presence of high-quality evidence, however, does not necessarily translate into improved patient outcomes owing to the implementation gap. To advance understanding of how knowledge-based tools are being utilized in the routine clinical care of children with hydrocephalus, the HCRN-Quality (HCRNq) network was started in 2019. With a focus on CSF shunt infection, the authors present baseline data regarding CSF shunt infection rates and current shunt infection prevention practices in use at HCRNq sites.
METHODS: Baseline shunt surgery practices, infection rate, and risk factor data were prospectively collected within HCRNq. No standard infection protocol was recommended, but site use of a protocol was implied if at least 3 of 6 common shunt infection prevention practices were used in > 80% of shunt surgical procedures. Univariable and multivariable analyses of shunt infection risk factors were performed.
RESULTS: Thirty sites accrued data on 2437 procedures between November 2019 and June 2021. The unadjusted infection rate across all sites was 3.9% (range 0%-13%) and did not differ among shunt insertion, shunt revision, or shunt insertion after infection. Protocol use was implied for only 15/30 centers and 60% of shunt operations. On univariable analysis, iodine/DuraPrep (OR 0.57, 95% CI 0.37-0.88, p = 0.02) and the use of an antibiotic-impregnated catheter in any segment of the shunt (or both) decreased infection risk (OR 0.53, 95% CI 0.34-0.82, p = 0.01). Iodine-based prep solutions (OR 0.56, 95% 0.36-0.86, p = 0.02) and the use of antibiotic-impregnated catheters (OR 0.52, 95% CI 0.34-0.81, p = 0.01) retained significance in the multivariable model, but no relationship between protocol use and infection risk was demonstrated in this baseline analysis.
CONCLUSIONS: The authors have demonstrated that children undergoing CSF shunt surgery at HCRNq sites share similar demographic characteristics with other large North American multicenter cohorts, with similar observed baseline infection rates and risk factors. Many centers have implemented standardized shunt infection prevention practices, but considerable practice variation remains. As such, there is an opportunity to decrease shunt infection rates in these centers through continued standardization of care.

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).