Y-Shaped Branched Ventriculo-Peritoneal Shunt for Adult Multiloculated Hydrocephalus
Multiloculated hydrocephalus (MLH) is a complex condition characterized by the presence of multiple, non-communicating fluid-filled compartments within the brain. This condition is uncommon in adults and often arises as a result of neurosurgical interventions, hemorrhage, infection, or tumors. Unlike simple hydrocephalus, MLH cannot be easily managed through traditional methods such as endoscopic fenestration or unilateral ventriculo-peritoneal shunt (VPS). The primary goal of treatment in MLH is to restore communication between the trapped ventricular compartments. However, due to the variability in individual anatomy and cerebrospinal fluid (CSF) dynamics, there is no universally accepted surgical strategy for managing MLH.
Current treatment modalities for MLH include microsurgical fenestration of separate entrapments via endoscopy or craniotomy, shunt surgery with multiple catheters placed in trapped compartments, or a combination of these approaches. While neuro-endoscopy is often considered the first-line treatment, its effectiveness can be limited by individual anatomical complexities and the risk of fenestration closure. In cases where endoscopic fenestration is not feasible or has failed, Y-shaped branched VPS emerges as a viable alternative. This technique offers complementary advantages and is particularly effective in treating complex MLH, especially in cases of communicating hydrocephalus.
The Y-shaped branched VPS procedure involves the placement of multiple ventricular catheters connected to a single shunt valve via a Y-shaped connector. This approach allows for the simultaneous drainage of multiple trapped compartments, thereby addressing the unique challenges posed by MLH. The procedure begins with the creation of burr holes for bilateral frontal horn puncture, typically at Kocher’s point, which is located 2.5 cm anterior to the coronal suture and 2.5 cm lateral from the midline. In cases where the temporal horn is also trapped, an additional puncture is made at Frazier’s point, situated 3 cm lateral from the midline and 6 cm superior to the inion. The catheters are then guided subcutaneously to an incision on the parietal protuberance.
Next, an incision is made in the abdominal skin, and the peritoneal catheter is guided to the same parietal protuberance incision. The Y-shaped connector is then attached to the shunt valve and the peritoneal catheter. The branched double or triple ventricular catheters are connected to the Y-shaped connector, ensuring that CSF drainage flows smoothly. Finally, the peritoneal catheter is placed into the peritoneal cavity.
A retrospective consecutive case study was conducted on adult patients treated with Y-shaped branched VPS from 2012 to 2017. The study included 28 patients, with 16 males and 12 females, ranging in age from 17 to 68 years (mean age: 37 years ± 14 years). Among these patients, 12 had undergone tumor resection, 4 had undergone stereotactic biopsy, and 12 had received palliative treatment. Double-branch VPS was performed in 26 cases, with ventricular tips placed in the bilateral frontal horns in 22 cases, the frontal horn and temporal horn in 3 cases, and the frontal horn and subdural space in 1 case. Triple-branch VPS was performed in 2 cases, with ventricular tips located in the bilateral frontal horns and trapped temporal/occipital horn. Programmable and anti-siphon shunts were used in 25 patients, while fixed shunts were used in 3 patients.
The study reported long-term outcomes, with follow-up periods ranging from 0.5 to 95 months. The Karnofsky Performance Scale (KPS) improved in 25 patients and deteriorated in 3 patients. At the last follow-up, 13 patients had died, with 1 death attributed to shunt obstruction and the remaining 12 deaths due to tumor progression or other diseases. The 5-year overall survival rate was 53.6%, and the hydrocephalus-free survival rate was 89.6%. Procedural complications included intracranial infection in one case, inappropriate location of the ventricular tips in one case, and shunt obstruction in two cases. The overall complication rate was 14.3%, and the VPS revision rate was 10.7%.
Despite the limitations of the study, including its retrospective nature and small sample size, the results suggest that Y-shaped branched VPS is a viable treatment option for adult MLH. This technique offers several advantages, including simplicity, reliability, and lower revision rates compared to other treatment modalities. It is particularly suitable for cases where endoscopic fenestration is not feasible, such as in patients with diffuse midline glioma involving the bilateral thalamus or severe adhesions. Additionally, Y-shaped branched VPS can serve as an optimal palliative treatment for tumors occluding the foramen of Monro, such as chordoid gliomas in the third ventricle, large pituitary adenomas, craniopharyngiomas, or malignant teratomas.
When implementing Y-shaped branched VPS, the accurate placement of ventricular catheter tips is crucial. For trapped frontal horns, the catheter tip should be positioned just in front of the foramen of Monro through Kocher’s point. For trapped temporal horns, the catheter tip should be located near the front wall of the temporal horn, away from the choroid plexus, through Frazier’s point. The use of neuro-navigation or Sina neurosurgical assist (Sina) can aid in the precise placement of ventricular tips. Additionally, the use of a pressure-adjustable valve is recommended to minimize the risk of over-drainage, which is a leading cause of VPS revision.
In conclusion, Y-shaped branched VPS is a valuable treatment option for adult MLH, particularly in cases where endoscopic fenestration is not feasible or has failed. This technique offers several advantages, including simplicity, reliability, and lower revision rates, making it a viable alternative for managing complex MLH. Future clinical randomized controlled trials with larger sample sizes are needed to further validate the efficacy of this approach.
doi.org/10.1097/CM9.0000000000001961
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