Hydrocephalus in the Elderly: Surgical Management of Idiopathic Normal Pressure Hydrocephalus

Isaacs, Albert M.; Williams, Michael A.; Hamilton, Mark G.

doi:10.1007/978-3-319-40232-1_26

Cited by 6 publications

(7 citation statements)

References 132 publications

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“…The general aspects associated with the surgical approach for VP shunt insertion have been described elsewhere. 24 With regard to this study, there were three intervention changes: 1) a shunt infection-prevention strategy was implemented, and 2) frameless navigation was accomplished using AxiEM (Medtronic International), which was typically performed with preoperative MRI or CT prior to surgery. The entry site for insertion of the ventricular catheter was typically the posterior right side.…”

Section: Context and Interventionsmentioning

confidence: 99%

“…All entry locations were selected based on image-guided preoperative planning, and passage of the ventricular catheter was undertaken with real-time use of the image guidance. 24 Programable shunt valves were consistently used. 24 3) The peritoneal catheter was inserted through a small right para-xiphoid location incision using an 11-Fr peel-away sheath and was positioned in the peritoneal cavity with laparoscopic assistance undertaken by a general surgeon.…”

Section: Context and Interventionsmentioning

confidence: 99%

“…24 Programable shunt valves were consistently used. 24 3) The peritoneal catheter was inserted through a small right para-xiphoid location incision using an 11-Fr peel-away sheath and was positioned in the peritoneal cavity with laparoscopic assistance undertaken by a general surgeon. In addition, a modification of the distal catheter insertion technique described by Svoboda et al 20 was used.…”

Section: Context and Interventionsmentioning

confidence: 99%

“…The shunt infection prevention bundle was implemented on July 1, 2013, and ran contemporaneously with the ShOut-QI study. 24,26 A continuous QI approach 17,27,28 was used. Study enrollment ended December 31, 2018.…”

Section: Study Timelinementioning

confidence: 99%

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Reducing the risks of proximal and distal shunt failure in adult hydrocephalus: a shunt outcomes quality improvement study

Isaacs

Ball

Sader

et al. 2022

Journal of Neurosurgery

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OBJECTIVE Patient outcomes of ventriculoperitoneal (VP) shunt surgery, the mainstay treatment for hydrocephalus in adults, are poor because of high shunt failure rates. The use of neuronavigation or laparoscopy can reduce the risks of proximal or distal shunt catheter failure, respectively, but has less independent effect on overall shunt failures. No adult studies to date have combined both approaches in the setting of a shunt infection prevention protocol to reduce shunt failure. The goal of this study was to determine whether combining neuronavigation and laparoscopy with a shunt infection prevention strategy would reduce the incidence of shunt failures in adult hydrocephalic patients. METHODS Adult patients (age ≥ 18 years) undergoing VP shunt surgery at a tertiary care institution prior to (pre–Shunt Outcomes [ShOut]) and after (post-ShOut) the start of a prospective continuous quality improvement (QI) study were compared. Pre-ShOut patients had their proximal and distal catheters placed under conventional freehand approaches. Post-ShOut patients had their shunts inserted with neuronavigational and laparoscopy assistance in placing the distal catheter in the perihepatic space (falciform technique). A shunt infection reduction protocol had been instituted 1.5 years prior to the start of the QI initiative. The primary outcome of interest was the incidence of shunt failure (including infection) confirmed by standardized criteria indicating shunt revision surgery. RESULTS There were 244 (115 pre-ShOut and 129 post-ShOut) patients observed over 7 years. With a background of shunt infection prophylaxis, combined neuronavigation and laparoscopy was associated with a reduction in overall shunt failure rates from 37% to 14%, 45% to 22%, and 51% to 29% at 1, 2, and 3 years, respectively (HR 0.44, p < 0.001). Shunt infection rates decreased from 8% in the pre-ShOut group to 0% in the post-ShOut group. There were no proximal catheter failures in the post-ShOut group. The 2-year rates of distal catheter failure were 42% versus 20% in the pre- and post-ShOut groups, respectively (p < 0.001). CONCLUSIONS Introducing a shunt infection prevention protocol, placing the proximal catheter under neuronavigation, and placing the peritoneal catheter in the perihepatic space by using the falciform technique led to decreased rates of infection, distal shunt failure, and overall shunt failure.

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Section: Context and Interventionsmentioning

confidence: 99%

Section: Context and Interventionsmentioning

confidence: 99%

Section: Context and Interventionsmentioning

confidence: 99%

Section: Study Timelinementioning

confidence: 99%

See 2 more Smart Citations

Reducing the risks of proximal and distal shunt failure in adult hydrocephalus: a shunt outcomes quality improvement study

Isaacs

Ball

Sader

et al. 2022

Journal of Neurosurgery

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“…The most common shunt types are the ventriculoperitoneal (VP), ventriculoatrial, and lumboperitoneal. [3][4][5] VP shunt implantation is a predominant neurosurgical procedure worldwide in both children and adults. [6][7][8] While treatment of hydrocephalus in adults with a CSF shunt is effective, the surgical procedure is frequently complicated by failure of the shunt system, which requires surgical revision.…”

mentioning

confidence: 99%

A standardized infection prevention bundle for reduction of CSF shunt infections in adult ventriculoperitoneal shunt surgery performed without antibiotic-impregnated catheters

Muram

Isaacs

Sader

et al. 2023

Journal of Neurosurgery

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OBJECTIVE Ventriculoperitoneal (VP) shunt insertion and revision surgeries are some of the most common procedures that are performed by neurosurgeons. Shunt infections within the adult population are associated with significant morbidity and mortality and rates remain high. The objective of the current study was to use quality improvement (QI) methodology to create a standardized infection prevention bundle aimed at reducing the rate of shunt infections. METHODS A prospective, single-center, single-surgeon QI study was undertaken. Patients were included if they were 18 years of age or older and were undergoing a VP shunt insertion or revision. The primary outcome of the study was the development of a shunt-related surgical site infection, within 1 year of surgery, as defined according to the Canadian Nosocomial Infection Surveillance Program guidelines. There was no standardized protocol prior to July 2013. A bundle coined as the Calgary Adult Shunt Infection Prevention Protocol (CASIPP) was implemented on July 1, 2013, and updated on July 1, 2015, when 2% chlorhexidine gluconate in 70% isopropyl alcohol replaced povidone-iodine for preoperative skin antisepsis. Protocol compliance was regularly monitored using a standardized process. No antibiotic-impregnated catheters were used. RESULTS A total of 621 consecutive VP shunt insertions and revisions were included in the study. The rate of shunt infection was 5.8% during the period in which there was no standardized shunt protocol. After the implementation of the CASIPP the infection rate decreased to 4.0%, and after introduction of the chlorhexidine/alcohol skin antisepsis, the infection rate was 0% in 379 consecutive procedures (p < 0.0001). Multivariable logistic regression analysis demonstrated that the use of chlorhexidine/alcohol with CASIPP was associated with a significant reduction in the odds of developing a shunt infection (OR 0.032, 95% CI 0–0.19, p = 0.0005). CONCLUSIONS The implementation of a standardized shunt infection prevention bundle within the adult population, without the use of antibiotic-impregnated catheters, significantly reduced the rate of shunt infections which was sustained over many years. The use of 2% chlorhexidine gluconate in 70% isopropyl alcohol for preoperative antisepsis may have played a significant role. Multicenter studies should be completed to verify the effectiveness of the authors’ protocol.

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Current Update on Treatment Strategies for Idiopathic Normal Pressure Hydrocephalus

Isaacs

Williams

Hamilton

2019

Curr Treat Options Neurol

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Hydrocephalus in the Elderly: Surgical Management of Idiopathic Normal Pressure Hydrocephalus

Cited by 6 publications

References 132 publications

Reducing the risks of proximal and distal shunt failure in adult hydrocephalus: a shunt outcomes quality improvement study

Reducing the risks of proximal and distal shunt failure in adult hydrocephalus: a shunt outcomes quality improvement study

A standardized infection prevention bundle for reduction of CSF shunt infections in adult ventriculoperitoneal shunt surgery performed without antibiotic-impregnated catheters

Current Update on Treatment Strategies for Idiopathic Normal Pressure Hydrocephalus

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