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A cerebral shunt is a device permanently implanted inside the head and body to drain excess fluid away from the brain. They are commonly used to treat hydrocephalus, the swelling of the brain due to excess buildup of cerebrospinal fluid (CSF). If left unchecked, the excess CSF can lead to an increase in intracranial pressure (ICP), which can cause intracranial hematoma, cerebral edema, crushed brain tissue or herniation. The drainage provided by a shunt can alleviate or prevent these problems in patients with hydrocephalus or related diseases. Shunts come in a variety of forms, but most of them consist of a valve housing connected to a catheter, the lower end of which is usually placed in the peritoneal cavity. The main differences between shunts are usually in the materials used to construct them, the types of valve (if any) used, and whether the valve is programmable or not. Description Valves types Shunt location The location of the shunt is determined by the neurosurgeon based on the type and location of the blockage causing hydrocephalus. All brain ventricles are candidates for shunting. The catheter is most commonly placed in the abdomen but other locations include the heart and lungs. Shunts can often be named after the route used by the neurosurgeon. The distal end of the catheter can be located in just about any tissue with enough epithelial cells to absorb the incoming CSF. Below are some common routing plans for cerebral shunts. Frazier's point It is located on the parietal bone, above the lambdoid suture, 3 to 4 cm lateral to the midline and 6 cm above the inion. It is a common site for ventricular cannulation in the context of inserting a ventriculoperitoneal shunt for the treatment of hydrocephalus. It was first described by C H Frazier in 1928. Shunt routing A subgaleal shunt is usually a temporary measure used in infants who are too small or premature to tolerate other shunt types. The surgeon forms a pocket beneath the epicranial aponeurosis (the subgaleal space) and allows CSF to drain from the ventricles, creating a fluid-filled swelling on the baby's scalp. These shunts are normally converted to VP or other shunt types once the infant is big enough. Indications Below is a short list of known complications that can lead to hydrocephalus requiring shunting. Complications There are a number of complications associated with shunt placement. Many of these complications occur during childhood and cease once the patient has reached adulthood. Many of the complications require immediate shunt revision (the replacement or reprogramming of the already existing shunt). The common symptoms often resemble a new onset of hydrocephalus, such as headaches, nausea, vomiting, double vision, and an alteration of consciousness. This can result in damage to an individual's short-term memory. In the pediatric population, the shunt failure rate two years after implantation has been estimated to be as high as 50%. Those patients with advanced age, prolonged hospital stay, GCS score of less than 13, extra-ventricular drains in situ, or excision of brain tumors are more likely to have early shunt malfunction. Infection Infection is a common complication that normally affects pediatric patients because they have not yet built up immunities to a number of different diseases. Normally, the incidence of infection decreases as the patient grows older and the body gains immunity to various infectious agents. Shunt infection can occur in up to 27% of patients. Infection can lead to long term cognitive defects, neurological problems, and in some cases death. Common microbial agents for shunt infection include Staphylococcus epidermidis, Staphylococcus aureus, and Candida albicans. Further factors that can lead to shunt infection include shunt insertion at a young age (less than six months old) and the type of hydrocephalus being treated. There is no strong correlation between infection and shunt type. Though the symptoms of a shunt infection are generally similar to the symptoms seen in hydrocephalus, infection symptoms can also include fever and elevated white blood cell counts. Treatment of shunt infections Treatment of a CSF shunt infection generally includes removal of the shunt and placement of a temporary ventricular reservoir until the infection is resolved. There are four main methods of treating ventriculoperitoneal (VP) shunt infections: (1) antibiotics; (2) removal of infected shunt with immediate replacement; (3) externalization of shunt with eventual replacement; (4) removal of infected shunt with external ventricular drain (EVD) placement and eventual shunt re-insertion. The last method has the highest success rate at over 95%. Medical treatment of shunt infection Initial empiric therapy for CSF shunt infection should include broad antibiotic coverage for gram-negative aerobic bacilli including pseudomonas as well as for gram-positive organisms including Staphylococcus aureus and coagulase-negative staphylococcus, such as a combination of ceftazidime and vancomycin. Some clinicians add parenteral or intrathecal aminoglycosides to enhance pseudomonas coverage, although the efficacy of the aminoglycosides is not clear. Meropenem and aztreonam are additional antibiotic options that are effective against gram-negative bacterial infections. Surgical treatment of shunt infection To evaluate the benefit of surgical shunt removal or externalization followed by removal, Wong et al. compared two groups: one with medical treatment alone, and another with medical and surgical treatment simultaneously. 28 patients with infection after ventriculoperitoneal shunt implantation over an 8-year period in their neurosurgical center were studied. 17 of these patients were treated with shunt removal or externalization followed by removal in addition to IV antibiotics while the other 11 were treated with IV antibiotics only. The group receiving both surgical shunt removal and antibiotics showed lower mortality – 19% versus 42% (p = 0.231). Despite the fact that these results are not statistically significant, Wong et al. suggest managing VP shunt infections via both surgical and medical treatment. An analysis of 17 studies published over the past 30 years regarding children with CSF shunt infections revealed that treating with both shunt removal and antibiotics successfully treated 88% of 244 infections, while antibiotic therapy alone successfully treated the CSF shunt infection in only 33% of 230 infections. While typical surgical methods of handling VP shunt infections involve removal and reimplantation of the shunt, different types of operations have used with success in select patients. Steinbok et al. treated a case of recurrent VP shunt infections in an eczematous patient with a ventriculosubgaleal shunt for two months until the eczema healed completely. This type of shunt allowed them to avoid the area of diseased skin that acted as the source of infection. Jones e.... Discover the Gary Fryns popular books. Find the top 100 most popular Gary Fryns books.