Post on 21-Mar-2019
transcript
To
Surgery
Hydrocephalus: Emergency Department v.1.1
Approval & Citation Explanation of Evidence RatingsSummary of Version Changes
Last Updated: 03/2016
Next Expected Revision:03/2021© 2016 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
For questions concerning this pathway,
contact: Hydrocephalus@seattlechildrens.org
AssessmentImaging
· DX shunt series
· CT Head w/o contrast STEALTH
· Abdominal signs or symptoms (acute abdomen)
· Early (< 3 months of shunt placement): abdominal CT IV/PO contrast
· Delayed (> 3 months of shunt placement): ultrasound abdomen - limited
Labs
· Concern for new hydrocephalus: CBC w/diff, PT/PTT
· Concern for shunt infection: CBC w/diff, ESR, CRP, serum glucose, BUN and serum
creatinine, blood cultures.
· Consider workup for other source of infection (could include respiratory panel,
urinalysis, throat culture, urine culture, stool culture, chest XR if indicated)
· Concern for shunt malfunction: CBC w/diff
Notify Neurosurgery after labs are resulted
· Neurosurgery to determine if and when to begin antibiotics
· Determine if surgery needed
· Shunt/Reservoir tap per shunt tap protocol below
· Shunt/Reservoir Tapping protocol
· Tap to be done by Neurosurgery only
· Tap if within 2 weeks of surgery with fever or
· Tap if within 3 months of surgery with fever and no other source of infection
· If > 3 months consider tap at neurosurgery discretion
· If shunt/reservoir tapped send CSF for gram stain, culture, cell count, protein
glucose, and bacterial PCR (use CSF Studies Orderset)
Definitions
Clinical signs of shunt
malfunction· Children < 1 year old – bulging
fontanelle, rapidly increasing OFC,
downward deviation of the eyes, less
interest in feeding
· Children > 1 year old – Headaches,
cranial nerve signs, changes in vision
· All ages – vomiting, lethargy,
swelling along shunt tract, irritability
without another recognized cause,
lethargy
· Please note that an isolated seizure
is not a prognostic indication of a
shunt malfunction
Clinical signs of shunt infection· Fever (38.5°C) and shunt placement
within last 3 months and no other
source of infection
· Fever (38.5°C) and shunt placement
within the last 2 weeks
· Wound overlying the implanted shunt
material
· Erythema, swelling or drainage from
incisions
· Redness along the shunt tract
New Hydrocephalus· Radiographic imaging with findings of
new hydrocephalus
Unstable Patient· Abnormal vital signs (bradycardia/
hypertension/altered respiratory rate,
obtunded/unresponsive)
Emergent Surgery: patient to OR in
<1 hour
Urgent Surgery: patient to OR in 1-4
hours (can be transferred to inpatient
unit)
No
Surgery
Off
Pathway
Surgery Preparation· Start admission process
· Initiate admission orders
· Admit patient directly to OR or to inpatient unit - see ED Job Aid: ED-OR Transfer for
Emergent or Urgent surgery (for SCH only)
Surgery Needed
· NOTIFY ED ATTENDING IMMEDIATELY
· Evaluate and stabilize: ABCD
· Elevate head of bed to 30 degrees/head midline
· Place on full monitors with BP to cycle every 15 minutes
· If seizing initiate Seizure Acute Management Pathway
· Notify Neurosurgery on call immediately
· Proceed with assessment
!Unstable?
Stable
Notify ED attending
For screening
Unstable
Inclusion Criteria
· New hydrocephalus including scheduled
referral, suspected shunt malfunction, or
suspected shunt infection
Exclusion Criteria
· <1 month of age, <44 wks PMA
· New brain tumor
· Non-accidental trauma/trauma
· Patients who undergo ETV who have
had prior shunt
Emergent Urgent
Assessment· NPO
· Conduct complete physical exam
including neuro exam
· Document Glascow Coma Score
Phase Change· Postop Shunt Placement
· Postop ETV
· Postop Infection
CT Head w/o contrast STEALTH
Postop ETV-CPC
Postop Shunt Placement
Postop Infection
Hydrocephalus: Clinic/Inpatient Admit v.1.1
Surgery
needed?No
Off
Pathway
Surgery Preparation· Start admission process
· Initiate admission orders
· Admit patient directly to OR or to inpatient unit (Emergent vs. Urgent)
Yes
To Surgery
AssessmentSend unstable patient to ER
Imaging
· New presentation hydrocephalus
· CT brain without contrast STEALTH
· MRI brain Hydrocephalus Protocol to evaluate if candidate for ETV, if indicated
· Shunt malfunction or shunt infection
· CT brain without contrast STEALTH
· If previous CT at Seattle Children’s: order low-dose CT
· If clinically stable and has Strata valve, non-programmable valve, or no valve:
order MRI brain HASTE
· XR Shunt Series
· Abdominal signs or symptoms (acute abdomen)
· Early (<3 months of shunt replacement): abdominal CT IV/PO contrast
· Delayed (>3 months of shunt placement): Ultrasound Abdomen – Limited
Labs
· Concern for new hydrocephalus: CBC w/ diff, PT/PTT
· Concern for shunt infection:
· CBC w/ diff, ESR, CRP, serum glucose, BUN and serum creatinine, blood
cultures
· Consider workup for other source of infection (could include respiratory panel,
urinalysis, throat culture, urine culture, stool culture, chest XR if indicated)
· Concern for shunt malfunction: CBC w/ diff
· Shunt/Reservoir tap per shunt tap protocol below
· Shunt/Reservoir Tapping protocol
· Tap to be done by Neurosurgery only
· Tap if within 2 weeks of surgery with fever or
· Tap if within 3 months of surgery with fever and no other source of
infection
· If > 3 months consider tap at neurosurgery discretion
· If shunt/reservoir tapped send CSF for gram stain, culture, cell count, protein
glucose, and bacterial PCR (use CSF Studies Orderset)
· Determine if surgery needed
Definitions
Clinical signs of shunt
malfunction· Children < 1 year old – bulging
fontanelle, rapidly increasing OFC,
downward deviation of the eyes, less
interest in feeding
· Children > 1 year old – Headaches,
cranial nerve signs, changes in vision
· All ages – vomiting, lethargy,
swelling along shunt tract, irritability
without another recognized cause,
lethargy
· Please note that an isolated seizure
is not a prognostic indication of a
shunt malfunction
Clinical signs of shunt infection· Fever (38.5°C) and shunt placement
within last 3 months and no other
source of infection
· Fever (38.5°C) and shunt placement
within the last 2 weeks
· Wound overlying the implanted shunt
material
· Erythema, swelling or drainage from
incisions
· Redness along the shunt tract
New Hydrocephalus· Radiographic imaging with findings of
new hydrocephalus
Unstable Patient· Abnormal vital signs (bradycardia/
hypertension/altered respiratory rate,
obtunded/unresponsive)
!
Inclusion Criteria
· New hydrocephalus including scheduled
referral, suspected shunt malfunction, or
suspected shunt infection
Exclusion Criteria
· <1 Month of age, <44 weeks PMA
· New brain tumor
· Non-accidental trauma/trauma
· Patients who undergo ETV who have
had prior shunt
Phase Change· Postop Shunt Placement
· Postop ETV
· Postop Infection
Last Updated: 03/2016
Next Expected Revision:03/2021© 2016 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
For questions concerning this pathway,
contact: Hydrocephalus@seattlechildrens.org
Approval & Citation Explanation of Evidence RatingsSummary of Version Changes
Imaging
Hydrocephalus: Postop Shunt Placement/Revision v.1.1
Management
Discharge
Instructions· Follow-up with
neurosurgery NP in 2
weeks for wound
check, and with
neurosurgeon in 6
weeks for HASTE MR/
CT
· Patient transferred from OR to inpatient unit
· Vitals:
· Neurological checks: q2 hours x 6hours; q 4 hours till
discharge
· Monitors: Continuous cardiorespiratory monitors x 12
hours then only when asleep
· Activity: Ad Lib
· Nursing: see Hydrocephalus GOC
· Elevate head of bed to 30 degrees
· Bathing: patient may bathe at 48 hours postoperative; no
soaking.
· Diet: Standard diet
· Fluids:
· ≥ 1 month of age: D5NS + KCl 20 mEq/L
· Post-op Imaging:
· CT scan
· DX shunt series
· Medications
· Miralax/Docusate scheduled, suppository or senna PRN
· Pain:
· Acetaminophen scheduled x 1 day then PRN
starting in OR/PACU.
· Alternate ibuprofen with acetaminophen, but delay
starting ibuprofen until 4 hours postop to minimize
bleeding risk
· Labs: none
· Place discharge orders (anticipated 24-48 hours)
Discharge Criteria· Afebrile x 24 hours
· Tolerating PO/PO pain med
· No nausea or vomiting
· Tolerating up out of bed.
Inclusion Criteria
· Postop shunt placement
Exclusion Criteria
· < 1 Month of age, <44 weeks PMA
· New brain tumor
· Non-accidental trauma/trauma
· Patients who undergo ETV who
have had prior shunt
Last Updated: 03/2016
Next Expected Revision:03/2021© 2016 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
For questions concerning this pathway,
contact: Hydrocephalus@seattlechildrens.org
Approval & Citation Explanation of Evidence RatingsSummary of Version Changes
Hydrocephalus GOC (for SCH only)
≥ 5 years
< 5 years
Patient Age
Outpatient Follow-up
Shunt
Haste MRI yearly
· Follow up every other year with a
HASTE MRI and shunt series
· If patient has codman: CT every
other year per provider discretion
Management
Discharge
Instructions· Follow-up with
neurosurgery NP in 2
weeks for wound
check, and with
neurosurgeon in 6
weeks for HASTE
MRI/CT
· Patient transferred from OR to inpatient unit
· Vitals:
· Neurological checks: q2 hours x 6hours; q 4 hours till
discharge
· Monitors: Continuous cardiorespiratory monitors x 12
hours then only when asleep
· Activity: Ad Lib
· Nursing: see Hydrocephalus GOC
· Elevate head of bed to 30 degrees
· Bathing: patient may bathe at 48 hours postoperative; no
soaking.
· Diet: Standard diet
· Fluids:
· ≥ 1 month of age: D5NS + KCl 20 mEq/L
· Post-op Imaging:
· CT scan
· DX shunt series
· Medications
· Miralax/Docusate scheduled, suppository or senna PRN
· Pain:
· Acetaminophen scheduled x 1 day then PRN
starting in OR/PACU.
· Alternate ibuprofen with acetaminophen, but delay
starting ibuprofen until 24 hours postop to minimize
bleeding risk
· Labs: Check sodium night of surgery and next AM
· Place discharge orders (anticipated 24-48 hours)
Discharge Criteria· Afebrile x 24 hours
· Tolerating PO/PO pain med
· No nausea or vomiting
· Tolerating up out of bed.
Hydrocephalus: Endoscopic Third Ventriculostomy (ETV)/
Choroid Plexus Cauterization v.1.1
Inclusion Criteria· Postop ETV/CPC
Exclusion Criteria· <1 Month of age, <44 weeks
PMA
· New brain tumor
· Non-accidental trauma/trauma
· Patients who undergo ETV who
have had prior shunt
Last Updated: 03/2016
Next Expected Revision:03/2021© 2016 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
For questions concerning this pathway,
contact: Hydrocephalus@seattlechildrens.org
Approval & Citation Explanation of Evidence RatingsSummary of Version Changes
≥ 5 years
< 5 years
Patient Age
Outpatient Follow-up
ETV
Haste MRI yearly
Order full CINE MRI first year,
followed by yearly HASTE MRI
Management
Hydrocephalus GOC (for SCH only)
Hydrocephalus: Suspected Shunt Infection v.1.1
Management
Phase
Change
Patient returns to OR for new shunt
· Diet: Regular Diet
· Fluids:
· ≥ 1 month of age: D5NS +20KCl
· Fluid replacement NS 1:1 for drain output
· Medications
· Miralax/Docusate scheduled, suppository or senna PRN
· Pain:
· Acetaminophen scheduled x 1 day then PRN starting
in OR/PACU
· Oxycodone PRN for breakthrough pain
· Consult Infectious Disease
· Initiate antibiotics in consultation with ID
· Patient transferred from OR to inpatient unit
· Vitals:
· Neurological checks: q 2 hours x 6 hours then q 4 hours
· Monitors: Continuous CR monitors
· Activity: Bedrest. Out of bed with drain clamps 30 mins x 3
times/day
· Nursing: see Hydrocephalus GOC and
P&P: Ventriculostomy and Lumbar Drain Care
· PICC line
· Elevate head of bed to 30 degrees
· Bacitracin to insertion site BID
· No bathing with EVD in place
· Record strict I&O
· Refer to orders for EVD output parameters Click here for guidance on empiric antibiotic therapy
Monitor Response to Therapy
· Check CSF gram stain, culture, cell count, glucose, and
protein
· Obtain CSF from ventriculostomy catheter (not the bag).
· Order daily until there are 3 negative cultures, then every
Monday/Thursday
· Check CBC/differential daily for 7 days then Monday/Thursday
· Check ESR/CRP, electrolytes every other day for 7 days then
Monday/Thursday
· For ventriculitis caused by gram-negative organisms, order
MRI with and without contrast prior to discontinuing therapy
· For Complicated CSF Shunt Infection
· Consider CT scan of head with contrast, bone scan,
antibiotic levels in CSF to investigate reasons for
persistent sites of infection
· Additional or prolonged therapy may be necessary,
consult outpatient ID
· Insert new shunt after definitive completion of antibiotic
therapy
Inclusion Criteria· Postop suspected shunt or CSF
infection
Exclusion Criteria· <1 Month of age, <44 weeks PMA
· New brain tumor
· Non-accidental trauma/trauma
· Patients who undergo ETV who
have had prior shunt
Last Updated: 03/2016
Next Expected Revision:03/2021© 2016 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
For questions concerning this pathway,
contact: Hydrocephalus@seattlechildrens.org
Approval & Citation Explanation of Evidence RatingsSummary of Version Changes
P&P: Ventriculostomy and Lumbar Drain Care (for SCH Only)Hydrocephalus GOC
Hydrocephalus Approval & Citation
Approved by the CSW Hydrocephalus for 3/1/2016
CSW Hydrocephalus Team:
CSW Owner: Sam Browd, MD
Neurosurgery, Nurse Practitioner: Angela Forbes, RN, MN, ARNP
Neurosurgery, Nurse Practitioner: Mandy Breedt, RN, MN, ARNP
Clinical Pharmacist: Anna Zhen
Eric Harvey, PharmD, MBA
Pharmacy Informatics: Rebecca Ford, PharmD
Emergency Department, CNS: Sara Fenstermacher, RN, MSN, CPN
Surgery, CNS Erin Moriarty, RN, MSN, CPN
Surgery, CNS Kristine Lorenzo, RN
Emergency Department, Physician: Ryan Kearney, MD
Emergency Department, Physician: Russ Migita, MD
Laboratory: Xuan Qin, PhD
Radiology, Physician: Dennis Shaw, MD
Clinical Effectiveness Team:
Consultant: Jennifer Hrachovec, PharmD, MPH
Project Manager: Kate Drummond, MS, MPA
Project Manager: Gioia Gonzalez, MSW, LICSW
CE Analyst: Nate Deam, MHA
CIS Informatician: Michael Leu, MD
CIS Analyst: Heather Marshall
Librarian: Sue Groshong, MLS
Project Manager Associate: Asa Herrman
Executive Approval:
Sr. VP, Chief Medical Officer Mark Del Beccaro, MD
Sr. VP, Chief Nursing Officer Madlyn Murrey, RN, MN
Surgeon-in-Chief Bob Sawin, MD
Retrieval Website: http://www.seattlechildrens.org/pdf/hydrocephalus-pathway.pdf
Please cite as:
Seattle Children’s Hospital, Browd S, Breedt Mandy, Drummond K, Fenstermacher S, Forbes A,
Ford R, Gonzalez G, Hrachovec J, Kearney R, Leu M, Lorenzo K, Migita R, Moriarty E , Shaw D,
2016 March. Hydrocephalus Pathway. Available from: http://www.seattlechildrens.org/pdf/
hydrocephalus-pathway.pdf
Return to ED Return to Clinic
Evidence Ratings
We used the GRADE method of rating evidence quality. Evidence is first assessed as to
whether it is from randomized trial, or observational studies. The rating is then adjusted in the following manner:
Quality ratings are downgraded if studies:• Have serious limitations
• Have inconsistent results• If evidence does not directly address clinical questions• If estimates are imprecise OR
• If it is felt that there is substantial publication bias
Quality ratings can be upgraded if it is felt that:• The effect size is large• If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR• If a dose-response gradient is evident
Quality of Evidence: High quality
Moderate quality
Low quality
Very low quality
Expert Opinion (E)
Reference: Guyatt G et al. J Clin Epi 2011: 383-394
To Bibliography Return to ED Return to Clinic
Summary of Version Changes
· Version 1 (3/1/2016): Go live
· Version 1.1 (3/9/2016): Removed amphotericin dosing
Return to ED Return to Clinic
Medical Disclaimer
Medicine is an ever-changing science. As new research and clinical experience
broaden our knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to
provide information that is complete and generally in accord with the standards
accepted at the time of publication.
However, in view of the possibility of human error or changes in medical sciences,
neither the authors nor Seattle Children’s Healthcare System nor any other party
who has been involved in the preparation or publication of this work warrants that
the information contained herein is in every respect accurate or complete, and
they are not responsible for any errors or omissions or for the results obtained
from the use of such information.
Readers should confirm the information contained herein with other sources and
are encouraged to consult with their health care provider before making any
health care decision.
Return to ED Return to Clinic
Bibliography
Identification
Screening
Eligibility
Included
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535
To Bibliography, Pg 2
782 records identified
through database searching
2 additional records identified
through other sources
764 records after duplicates removed
764 records screened 613 records excluded
110 full-text articles excluded,
101 did not answer clinical question
8 did not meet quality threshold
1 outdated relative to other included study
151 records assessed for eligibility
41 studies included in pathway
Studies were identified by searching electronic databases using search strategies developed and executed by a medical librarian, Susan Groshong. Searches were performed in August and September, 2013. The following databases were searched – on the Ovid platform: Medline, Cochrane Database of Systematic Reviews (2005 to date), Cochrane Central Register of Controlled Trials; elsewhere: Embase, CINAHL, Clinical Evidence, National Guideline Clearinghouse, TRIP, Cincinnati Children’s Evidence-Based Care Guidelines, Registered Nurses' Association of Ontario and Nursing+. Retrieval was limited to ages 0 – 18 (0 – 24 in Medline), English language and 2002 to current. In Medline and Embase, appropriate Medical Subject Headings (MeSH) and Emtree headings were used respectively, along with text words, and the search strategy was adapted for other databases using their controlled vocabularies, where available, along with text words. Concepts searched were hydrocephalus, ventricular or cerebrospinal shunts, ventriculostomy and any of the following: diagnostic imaging, laboratory tests, infections, postoperative care. All retrieval was further limited to certain evidence categories, such as relevant publication types, Clinical Queries, index terms for study types and other similar limits. Additional articles were identified by team members and added to results.
Susan Groshong, MLIS
December 2, 2013
Return to ED Return to Clinic
Bibliography
To Bibliography, Pg 2
Arnell K, Cesarini K, Lagerqvist-Widh A, Wester T, Sjolin J. Cerebrospinal fluid shunt infections in
children over a 13-year period: Anaerobic cultures and comparison of clinical signs of
infection with propionibacterium acnes and with other bacteria. J Neurosurg Pediatrics
[Hydrocephalus]. 2008;1(5):366-372.
Banks JT, Bharara S, Tubbs RS, et al. Polymerase chain reaction for the rapid detection of
cerebrospinal fluid shunt or ventriculostomy infections. Neurosurgery [Hydrocephalus
(Added)]. 2005;57(6):1237-43; discussion 1237-43.
Baradkar VP, Mathur M, Sonavane A, Kumar S. Candidal infections of ventriculoperitoneal shunts.
J Pediatr Neurosci [Hydrocephalus]. 2009;4(2):73-75.
Baykan N, Isbir O, Gercek A, Dagcnar A, Ozek MM. Ten years of experience with pediatric
neuroendoscopic third ventriculostomy: Features and perioperative complications of 210
cases. J Neurosurg Anesthesiol [Hydrocephalus]. 2005;17(1):33-37.
Benca J, Ondrusova A, Huttova M, Rudinsky B, Kisac P, Bauer F. Neuroinfections due to
enterococcus faecalis in children. Neuroendocrinol Lett [Hydrocephalus]. 2007;28(Suppl
2):32-33.
Bhatia R, Tahir M, Chandler CL. The management of hydrocephalus in children with posterior
fossa tumours: The role of pre-resectional endoscopic third ventriculostomy. Pediatr
Neurosurg [Hydrocephalus]. 2009;45(3):186-191. Accessed 09/23/2013. http://dx.doi.org/
10.1159/000222668.
Bouras T, Sgouros S. Complications of endoscopic third ventriculostomy. World Neurosurg
[Hydrocephalus]. 2013;79(2 Suppl):S22.e9-12.
Bouras T, Sgouros S. Complications of endoscopic third ventriculostomy. J Neurosurg Pediatrics
[Hydrocephalus]. 2011;7(6):643-649. Accessed 20110602; 8/13/2013 5:50:53 PM. http://
dx.doi.org/10.3171/2011.4.PEDS10503.
Buxton N, Turner B, Ramli N, Vloeberghs M. Changes in third ventricular size with
neuroendoscopic third ventriculostomy: A blinded study. J Neurol Neurosurg Psychiatry
[Hydrocephalus]. 2002;72(3):385-387.
Chern JJ, Muhleman M, Tubbs RS, et al. Clinical evaluation and surveillance imaging in children
with spina bifida aperta and shunt-treated hydrocephalus. J Neurosurg Pediatrics
[Hydrocephalus]. 2012;9(6):621-626. Accessed 09/23/2013. http://dx.doi.org/10.3171/
2012.2.PEDS11353.
Chugh A, Husain M, Gupta RK, Ojha BK, Chandra A, Rastogi M. Surgical outcome of tuberculous
meningitis hydrocephalus treated by endoscopic third ventriculostomy: Prognostic factors and
postoperative neuroimaging for functional assessment of ventriculostomy. J Neurosurg
Pediatrics [Hydrocephalus]. 2009;3(5):371-377.
Cinalli G, Spennato P, Ruggiero C, et al. Complications following endoscopic intracranial
procedures in children. Childs Nerv Syst [Hydrocephalus]. 2007;23(6):633-644.
Conen A, Walti LN, Merlo A, Fluckiger U, Battegay M, Trampuz A. Characteristics and treatment
outcome of cerebrospinal fluid shunt-associated infections in adults: A retrospective analysis
over an 11-year period. Clin Infect Dis [Hydrocephalus]. 2008;47(1):73-82. Accessed 09/23/
2013. http://dx.doi.org/10.1086/588298.
Desai KR, Babb JS, Amodio JB. The utility of the plain radiograph "shunt series" in the evaluation
of suspected ventriculoperitoneal shunt failure in pediatric patients. Pediatr Radiol
[Hydrocephalus]. 2007;37(5):452-456.
Return to ED Return to Clinic
Bibliography
Di Rocco F, Grevent D, Drake JM, et al. Changes in intracranial CSF distribution after ETV. Childs
Nerv Syst [Hydrocephalus]. 2012;28(7):997-1002. Accessed 09/23/2013. http://dx.doi.org/
10.1007/s00381-012-1752-6.
Dincer A, Yildiz E, Kohan S, Memet Ozek M. Analysis of endoscopic third ventriculostomy patency
by MRI: Value of different pulse sequences, the sequence parameters, and the imaging planes
for investigation of flow void. Childs Nerv Syst [Hydrocephalus]. 2011;27(1):127-135. Accessed
09/23/2013. http://dx.doi.org/10.1007/s00381-010-1219-6.
Faggin R, Calderone M, Denaro L, Meneghini L, d'Avella D. Long-term operative failure of
endoscopic third ventriculostomy in pediatric patients: The role of cine phase-contrast MR
imaging. Neurosurg focus [Hydrocephalus]. 2011;30(4):E1. Accessed 09/23/2013. http://
dx.doi.org/10.3171/2011.1.FOCUS10303.
Fukuhara T, Luciano MG, Kowalski RJ. Clinical features of third ventriculostomy failures classified
by fenestration patency. Surg Neurol [Hydrocephalus]. 2002;58(2):102-110.
Hader WJ, Walker RL, Myles ST, Hamilton M. Complications of endoscopic third ventriculostomy in
previously shunted patients. Neurosurgery [Hydrocephalus]. 2008;63(1 Suppl 1):ONS168-74.
Accessed 09/23/2013. http://dx.doi.org/10.1227/01.neu.0000335032.31144.17.
Iskandar BJ, Sansone JM, Medow J, Rowley HA. The use of quick-brain magnetic resonance
imaging in the evaluation of shunt-treated hydrocephalus. J Neurosurg [Hydrocephalus].
2004;101(2 Suppl):147-151.
James HE, Bradley JS. Management of complicated shunt infections: A clinical report. J Neurosurg
Pediatrics [Hydrocephalus]. 2008;1(3):223-228.
James HE, Bradley JS. Aggressive management of shunt infection: Combined intravenous and
intraventricular antibiotic therapy for twelve or less days. Pediatr Neurosurg [Hydrocephalus].
2008;44(2):104-111. Accessed 09/23/2013. http://dx.doi.org/10.1159/000113111.
Kim YK, Shin HJ, Kim YJ. A fifteen-year epidemiological study of ventriculoperitoneal shunt
infections in pediatric patients: A single center experience. Korean J Pediatr Infect Dis
[Hydrocephalus]. 2012;19(3):141-148.
Lang SS, Bauman JA, Aversano MW, et al. Hyponatremia following endoscopic third
ventriculostomy: A report of 5 cases and analysis of risk factors. J Neurosurg Pediatrics
[Hydrocephalus]. 2012;10(1):39-43. Accessed 09/23/2013. http://dx.doi.org/10.3171/
2012.4.PEDS1222.
Lehnert BE, Rahbar H, Relyea-Chew A, Lewis DH, Richardson ML, Fink JR. Detection of ventricular
shunt malfunction in the ED: Relative utility of radiography, CT, and nuclear imaging. Emerg
Radiol [Hydrocephalus]. 2011;18(4):299-305. Accessed 09/23/2013. http://dx.doi.org/10.1007/
s10140-011-0955-6.
Lo CH, Spelman D, Bailey M, Cooper DJ, Rosenfeld JV, Brecknell JE. External ventricular drain
infections are independent of drain duration: An argument against elective revision. J
Neurosurg [Hydrocephalus]. 2007;106(3):378-383.
Miller JH, Walkiewicz T, Towbin RB, Curran JG. Improved delineation of ventricular shunt catheters
using fast steady-state gradient recalled-echo sequences in a rapid brain MR imaging protocol
in nonsedated pediatric patients. AJNR Am J Neuroradiol [Hydrocephalus]. 2010;31(3):430-
435. Accessed 09/23/2013. http://dx.doi.org/10.3174/ajnr.A1866.
Morton RP, Reynolds RM, Ramakrishna R, et al. Low-dose head computed tomography in children:
A single institutional experience in pediatric radiation risk reduction: Clinical article. J
Neurosurg Pediatr [Hydrocephalus (Added)]. 2013;12(4):406-410.
To Bibliography, Pg 2 Return to ED Return to Clinic
Bibliography
O'Brien D, Stevens NT, Lim CH, et al. Candida infection of the central nervous system following
neurosurgery: A 12-year review. Acta Neurochir (Wien) [Hydrocephalus]. 2011;153(6):1347-
1350. Accessed 09/23/2013. http://dx.doi.org/10.1007/s00701-011-0990-9.
Pitetti R. Emergency department evaluation of ventricular shunt malfunction: Is the shunt series
really necessary?. Pediatr Emerg Care [Hydrocephalus]. 2007;23(3):137-141. Accessed 09/23/
2013.
Rozovsky K, Ventureyra EC, Miller E. Fast-brain MRI in children is quick, without sedation, and
radiation-free, but beware of limitations. J Clin Neurosci [Hydrocephalus]. 2013;20(3):400-405.
Accessed 09/23/2013. http://dx.doi.org/10.1016/j.jocn.2012.02.048.
Schuhmann MU, Ostrowski KR, Draper EJ, et al. The value of C-reactive protein in the
management of shunt infections. J Neurosurg [Hydrocephalus]. 2005;103(3 Suppl):223-230.
Schwartz S, Ruhnke M, Ribaud P, et al. Improved outcome in central nervous system aspergillosis,
using voriconazole treatment. Blood [Hydrocephalus]. 2005;106(8):2641-2645.
Simon TD, Hall M, Dean JM, Kestle JR, Riva-Cambrin J. Reinfection following initial cerebrospinal
fluid shunt infection. J Neurosurg Pediatrics [Hydrocephalus]. 2010;6(3):277-285. Accessed
09/23/2013. http://dx.doi.org/10.3171/2010.5.PEDS09457.
St George E, Natarajan K, Sgouros S. Changes in ventricular volume in hydrocephalic children
following successful endoscopic third ventriculostomy. Childs Nerv Syst [Hydrocephalus].
2004;20(11-12):834-838.
Tuan TJ, Thorell EA, Hamblett NM, Kestle JR, Rosenfeld M, Simon TD. Treatment and
microbiology of repeated cerebrospinal fluid shunt infections in children. Pediatr Infect Dis J
[Hydrocephalus]. 2011;30(9):731-735. Accessed 09/23/2013. http://dx.doi.org/10.1097/
INF.0b013e318218ac0e.
Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial
meningitis. Clin Infect Dis [Hydrocephalus]. 2004;39(9):1267-1284. Accessed 20041020; 8/13/
2013 5:50:53 PM.
Vassilyadi M, Tataryn ZL, Alkherayf F, Udjus K, Ventureyra EC. The necessity of shunt series. J
Neurosurg Pediatrics [Hydrocephalus]. 2010;6(5):468-473. Accessed 09/23/2013. http://
dx.doi.org/10.3171/2010.8.PEDS09557.
Williams TA, Leslie GD, Dobb GJ, Roberts B, van Heerden PV. Decrease in proven ventriculitis by
reducing the frequency of cerebrospinal fluid sampling from extraventricular drains. J
Neurosurg [Hydrocephalus]. 2011;115(5):1040-1046. Accessed 09/23/2013. http://dx.doi.org/
10.3171/2011.6.JNS11167.
Yilmaz A, Dalgic N, Musluman M, Sancar M, Colak I, Aydin Y. Linezolid treatment of shunt-related
cerebrospinal fluid infections in children. J Neurosurg Pediatrics [Hydrocephalus].
2010;5(5):443-448. Accessed 09/23/2013. http://dx.doi.org/10.3171/2009.12.PEDS09421.
Zorc JJ, Krugman SD, Ogborn J, Benson J. Radiographic evaluation for suspected cerebrospinal
fluid shunt obstruction. Pediatr Emerg Care [Hydrocephalus]. 2002;18(5):337-340.
Return to ED Return to Clinic