Neuroendoscopic aspiration and lavage of intraventricular empyema following shunt infection in infants

Abstract

Bacterial ventriculitis is one of the most common and serious complications of shunt placement. Shunt infection has varied management and is difficult to treat neurosurgically. We report a case of intraventricular empyema due to shunt infection. Standard management was failed for this case and reaccumulation of pus in the both ventricles. Neuroendoscopic surgery with intraventricular lavage and aspiration using cannula nasogastric tube (NGT) through a single burr hole, has successfully decreased the accumulation of intraventricular empyema. After lavage and aspiration, antibiotic can be distributed effectively to the affected area. Follow up imaging and cerebrospinal fluid (CSF) culture shown a good result and shorter length of stay in the hospital. Neuroendoscopy appears effective and safe for the management of bacterial ventriculitis due to shunt infection in infant. The strategy described in this report might be useful to treat intraventricular empyema.

Serial Neuroendoscopic Lavage for the Treatment of Elevated Cerebrospinal Fluid Protein Levels in Infants with Gram-Negative Rod Ventriculitis

“…In the presented cases, CSF protein levels decreased an average of 74% following each lavage (Fig. 3), which is consistent with previous reports [12, 13]. Unique to the cases reported here, serial CSF protein studies revealed that hyperproteinorrachia persisted beyond the resolution of active infection in 3 of the 5 cases (cases 1–3), and serial lavage was used to normalize CSF protein prior to shunt reinsertion.…”

“…Furthermore, there is discordance in the literature regarding the appropriate timing of neuroendoscopic lavage in the course of infection. While some studies recommend neuroendoscopic lavage be performed after 2 weeks of antibiotic treatment with unsatisfactory results [17, 21], others suggest lavage be pursued immediately after diagnosis of ventriculitis to improve the circulation of antibiotics [12]. Future studies should seek to identify clinical markers for the timing of initiation of treatment with serial lavage, as well as timing between treatments, to properly assess its utility.…”

“…The shunt is replaced after a course of antibiotics, serial negative cerebrospinal fluid (CSF) cultures, and normalization of CSF protein levels [8]. Preliminary studies suggest that application of neuroendoscopic intraventricular lavage in the setting of GNR ventriculitis may significantly reduce CSF protein levels and bacterial burden (and thereby, infection duration) [9][10][11][12][13][14][15], as well as reduce the incidence of post-infectious complications of shunt obstruction and multiloculated hydrocephalus requiring a complex shunt construct [12,13,16,17]. This report describes five infants with shunt-dependent hydrocephalus and GNR ventriculitis, which were effectively managed with serial neuroendoscopic lavage in addition to standard care measures.…”

Outcome improvement in cerebral ventriculitis after ventricular irrigation: a prospective controlled study

“…14 Also, Tandean et al reported a lavage and aspiration using a single burr hole in a case of intraventricular empyema after shunt infection in an infant who failed standard management. 10,21 While Shang et al reported 19 patients diagnosed with ventriculitis and treated with ventricular lavage caused by gram-negative bacteria, 10 Pandey et al reported the outcomes in 19 patients with gram-negative multi-/extensive drug-resistant bacilli. 9 In another study by Wang et al, 41 patients were diagnosed with ventriculitis from 7 different centers and managed with neuroendoscopic lavage.…”

Technical Nuances in Neuroendoscopic Lavage for Germinal Matrix Hemorrhage in Preterm Infants: Twenty Tips and Pearls after More than One Hundred Procedures

“…NEL, like every technique, requires a learning curve to master it. Several articles have been published around the utility of this technique for germinal matrix hemorrhage and ventriculitis [22][23][24]. However, in these articles the technique is described in a general way and, to date, none of them have detailed the tip and tricks around this very specific and complex surgical procedure.…”