Shunt infusion studies: impact on patient outcome, including health economics

Funder: University of CambridgeAbstract: Objectives: The diagnosis of shunt malfunction is often not straightforward. We have explored, in symptomatic shunted patients with hydrocephalus or pseudotumour cerebri syndrome (PTCS), the accuracy of CSF infusion tests in differentiating a functioning shunt from one with possible problems, and the health economic consequences. Methods: Participants: hydrocephalus/PTCS patients with infusion tests performed from January 2013 until December 2015. We followed patients up after 6 and 12 months from the test to determine whether they had improved, had persisting symptoms or had required urgent revision. We calculated the total cost savings of revision versus infusion tests and standard protocol of revision and ICP monitoring versus infusion tests. Results: Three hundred sixty-five shunt infusion tests had been performed where a shunt prechamber/reservoir was present. For hydrocephalus patients, more than half of the tests (~ 55%, 155 out of 280) showed no shunt malfunction versus 125 with possible malfunction (ages 4 months to 90 years old). For PTCS patients aged 10 to 77 years old, 47 had possible problems and 38 no indication for shunt malfunction. Overall, > 290 unnecessary revisions were avoided over 3 years’ time. Two hundred fifty-eight (> 85%) of those non-surgically managed, remained well, did not deteriorate and did not require surgery. No infections were associated with infusion studies. For Cambridge, the overall savings from avoiding revisions was £945,415 annually. Conclusions: Our results provide evidence of the importance of shunt testing in vivo to confirm shunt malfunction. Avoiding unnecessary shunt revisions carries a strong health benefit for patients that also translates to a significant financial benefit for the National Health Service and potentially for other healthcare systems worldwide

Shunt infusion studies: impact on patient outcome, including health economics

Funder: University of CambridgeAbstract: Objectives: The diagnosis of shunt malfunction is often not straightforward. We have explored, in symptomatic shunted patients with hydrocephalus or pseudotumour cerebri syndrome (PTCS), the accuracy of CSF infusion tests in differentiating a functioning shunt from one with possible problems, and the health economic consequences. Methods: Participants: hydrocephalus/PTCS patients with infusion tests performed from January 2013 until December 2015. We followed patients up after 6 and 12 months from the test to determine whether they had improved, had persisting symptoms or had required urgent revision. We calculated the total cost savings of revision versus infusion tests and standard protocol of revision and ICP monitoring versus infusion tests. Results: Three hundred sixty-five shunt infusion tests had been performed where a shunt prechamber/reservoir was present. For hydrocephalus patients, more than half of the tests (~ 55%, 155 out of 280) showed no shunt malfunction versus 125 with possible malfunction (ages 4 months to 90 years old). For PTCS patients aged 10 to 77 years old, 47 had possible problems and 38 no indication for shunt malfunction. Overall, > 290 unnecessary revisions were avoided over 3 years’ time. Two hundred fifty-eight (> 85%) of those non-surgically managed, remained well, did not deteriorate and did not require surgery. No infections were associated with infusion studies. For Cambridge, the overall savings from avoiding revisions was £945,415 annually. Conclusions: Our results provide evidence of the importance of shunt testing in vivo to confirm shunt malfunction. Avoiding unnecessary shunt revisions carries a strong health benefit for patients that also translates to a significant financial benefit for the National Health Service and potentially for other healthcare systems worldwide

Post-traumatic meningoencephalocele as a complication after head trauma and surgery: literature review focusing on the relevance of patient’s history and radiological follow-up

Abstract Background Meningoencephalocele (ME) is an herniation of brain parenchyma covered by meninges through a bone defect and could be malformative or secondary. Except for rarer cases of spontaneous form, ME is usually due to endonasal or otologic infections and rarely after head trauma. In predisposed patients, even mild head trauma can lead to the formation of a ME. Methods We performed a systematic review of literature with the aims to identify the clinical characteristics of all reported forms of post-traumatic ME and the best diagnostic and treatment strategy. We illustrated a case of a patient treated for a post-traumatic subdural hematoma who developed cerebrospinal fluid leakage 3 months after the trauma. Results The search returned a total of 59 papers for the analysis, including radiological, clinical studies, technical note and the case reported from our experience. The total number of patients collected for this review was 61, with a mean age of 31.1 years. The diagnosis of ME could be heterogeneous in terms of timing and clinical onset after a head injury. Symptoms onset and subsequent radiological diagnosis of ME vary between 24 h to 43 years. The majority of traumas were reported in temporal site (52.45%). There were reported high variability of treatment strategies dependent on the location and extent of the defect: in the majority of cases (58%), duroplasty by the heterologous dural patch was the procedure of choice. There is a relative low rate of complications (6.5%) due to a delayed diagnosis of ME. Conclusions When ME is associated with violation of meninges, the clinical presentation may be that of cerebrospinal fluid otorrhoea or otorhinorrhoea, consequently, delay in diagnosis can lead to neurological complications. The clinical effectiveness of ME treatment depends much more on the correct and timely diagnosis than on the type of procedure selected

Vertebral Body Erosion by a Chronic Contained Rupture of Thoracoabdominal Aortic Aneurysm: Systematic Review and Spine Surgical Recommendations

BACKGROUND: Vertebral body erosion (VBE) is commonly caused by neoplastic, inflammatory, or infectious diseases: it can be rarely associated with aortic wall disorders, such as chronic contained rupture of aortic aneurysm (CCR-AA). CCR-AA is a rare event comprising <5% of all reported cases. This condition is easily undiagnosed, differential diagnosis may be challenging, and there is no consensus or recommendation that dictates guidance on management of spinal surgical treatment.METHODS: We performed a systematic review of the literature of all cases of VBE secondary to CCR-AA to identify clinical, radiologic, and surgical outcome characteristics with the aim of providing a basis for future research studies.RESULTS: The search returned 80 patients. All reported patients had a history of hypertension. In almost all patients, the AA size reported was high (mean diameter, 7.056 cm). The treatment of this condition involves various reported treatment strategies: a totally conservative approach, treatment of the aortic aneurysm through a minimally invasive endovascular procedure, or an open surgery and combined approach. Despite the wide variability in therapeutic strategy, the rate of good outcomes was relatively high at 80%.CONCLUSIONS: Back pain and pain along the vertebral column are such frequent symptoms that unusual causes or serious and life-threatening complications may be overlooked. In addition to the common traumatic and degenerative causes of back pain, AA must also be considered. A combined approach between vascular and spine surgery could be achieved without any increased risk

Decompressive craniectomy for traumatic brain injury: patient age and outcome

The overall degree by which different patients may benefit from decompressive craniectomy (DC) remains controversial. In particular, the prognostic value of age has been investigated by very few studies. Many authors state there is no significant benefit in performing a DC in severe head injury after a certain age limit, with most placing the limit at 30-50 years of age. Between 1994 and 2004, 55 patients underwent DC at our institution. Advanced age did not constitute a contraindication to surgery for both ethical and cultural reasons. Thus, the data obtained were not biased by a selection of patients based on age. We analyzed potential predictors of outcome after DC, including sex, age, Glasgow Coma Scale (GCS), and presence of mass lesion. Chi-square test was used to compare categorical variables. The independent contribution of predictive factors to outcome was studied using logistic regression analysis. Initial GCS score was found to be an independent predictor of outcome (p = 0.001). No difference in the outcome was observed between patients with GCS 6-8 and GCS 9-15. These two groups have a better prognosis than patients with GCS 3-5. Logistic regression analysis showed age as an independent predictive factor to outcome (p = 0.005). A difference in outcome exists among patients over 65 and patients aged <or=65, while groups aged <40 and 40-65 showed no difference in outcome. Based on these findings, we believe that the age limit for performing DC should be revised

Blood flow velocities during experimental intracranial hypertension in pigs

OBJECTIVES: A purely hydraulic mechanism consisting in the pulsatile cuff-compression effect, by the cerebrospinal fluid displacement induced by the arterial pulsation, on the final portion of the bridging veins, has recently been hypothesized. This mechanism is able to maintain the constancy of cerebral blood flow (CBF) within the autoregulatory range, thus implying an exact balance between arterial inflow and venous outflow. In this study, we correlated arterial inflow and venous outflow during an experimentally induced condition of intracranial hypertension in pigs. METHODS: Mock cerebrospinal fluid (CSF) was progressively infused until a condition of brain tamponade was reached. Blood flow velocities at middle cerebral artery and sagittal sinus sites were evaluated simultaneously. RESULTS: Mean intracranial arterial blood flow velocity (IABFV), mean sagittal sinus blood flow velocity (SSBFV), and pulsatile-IABFV remained almost constant until cerebral perfusion pressure (CPP) dropped below 60-70 mmHg; then, a progressive decrease in mean IABFV and SSBFV, together with an increase in pulsatile-IABFV, was evident. CONCLUSION: The strict similarity between mean IABFV and SSBFV patterns suggests that CBF decrement is mainly due to a decrease in the venous outflow, which, in turn, produces an obstacle to the arterial inflow. The correspondent increase in pulsatile-IABFV confirms the presence of a distal outflow obstruction. All these findings point towards a purely hydraulic mechanism underlying the cerebral autoregulation which acts at the level of the so-called Starling resisto

Shunt infusion studies: impact on patient outcome, including health economics

Funder: University of CambridgeAbstract: Objectives: The diagnosis of shunt malfunction is often not straightforward. We have explored, in symptomatic shunted patients with hydrocephalus or pseudotumour cerebri syndrome (PTCS), the accuracy of CSF infusion tests in differentiating a functioning shunt from one with possible problems, and the health economic consequences. Methods: Participants: hydrocephalus/PTCS patients with infusion tests performed from January 2013 until December 2015. We followed patients up after 6 and 12 months from the test to determine whether they had improved, had persisting symptoms or had required urgent revision. We calculated the total cost savings of revision versus infusion tests and standard protocol of revision and ICP monitoring versus infusion tests. Results: Three hundred sixty-five shunt infusion tests had been performed where a shunt prechamber/reservoir was present. For hydrocephalus patients, more than half of the tests (~ 55%, 155 out of 280) showed no shunt malfunction versus 125 with possible malfunction (ages 4 months to 90 years old). For PTCS patients aged 10 to 77 years old, 47 had possible problems and 38 no indication for shunt malfunction. Overall, > 290 unnecessary revisions were avoided over 3 years’ time. Two hundred fifty-eight (> 85%) of those non-surgically managed, remained well, did not deteriorate and did not require surgery. No infections were associated with infusion studies. For Cambridge, the overall savings from avoiding revisions was £945,415 annually. Conclusions: Our results provide evidence of the importance of shunt testing in vivo to confirm shunt malfunction. Avoiding unnecessary shunt revisions carries a strong health benefit for patients that also translates to a significant financial benefit for the National Health Service and potentially for other healthcare systems worldwide

Global Neurocognitive and Frontal Functions analysis and Precision Intrathecal Pressure Measurement to Settle the Diagnostic Dilemma of the Normal Pressure Hydrocephalus: a preliminary experience

Normal Pressure Hydrocephalus (NPH) is a common condition associated with a cognitive deterioration and possibly involving up to 9-14% of all the over 65 years old nursing home residents. The purpose of the present paper is to introduce an inclusive study protocol aimed at increasing the diagnostic precision and follow-up accuracy