Use of a stop-flow programmable shunt valve to maximize CNS chemotherapy delivery in a pediatric patient with acute lymphoblastic leukemia

Abstract

Background:The requirement for frequent intraventricular drug delivery in the setting of shunt dependence is particularly challenging in the treatment of central nervous system infection, neoplastic disease, and hemorrhage. This is especially relevant in the pediatric population where both hematogenous malignancy requiring intrathecal drug delivery and shunt-dependent hydrocephalus are more prevalent. Intrathecal and intraventricular chemotherapy agents can be prematurely diverted in these shunt-dependent patients.Case Description:We report the use of a stop-flow programmable shunt valve to maximize delivery of intraventricular chemotherapy in a child with acute lymphoblastic leukemia and disseminated intravascular coagulation who presented with spontaneous intracerebral and intraventricular hemorrhages. The patient then developed posthemorrhagic hydrocephalus and eventually progressed to shunt dependence but still required frequent intraventricular chemotherapy administration. A ventriculoperitoneal shunt, equipped with a valve that allows for near cessation of cerebrospinal fluid flow (Certas®, Codman, Raynham, MA), and a contralateral Ommaya reservoir were inserted to maximize intraventricular dissemination of chemotherapy.Conclusions:To the best of our knowledge, this is the first reported case of the use of a high-resistance programmable valve being used to virtually cease cerebrospinal fluid flow through the distal catheter temporarily in order to maximize intraventricular drug dissemination in a pediatric patient with acute lymphoblastic leukemia.

Intracranial EEG Validation of Single-Channel Subgaleal EEG for Seizure Identification

“…Although studies of long-term EEG electrode implantation in the SG space are necessary, the safety of the SG space for chronic medical device implantation has been demonstrated by decades of successful intraventricular shunt valve and reservoir placements. 13…”

“…Although studies of long-term EEG electrode implantation in the SG space are necessary, the safety of the SG space for chronic medical device implantation has been demonstrated by decades of successful intraventricular shunt valve and reservoir placements. 13 In a recent study of chronically implanted subcutaneously EEG electrodes, 8 patients had EEGs recorded for as long as 9 weeks. 11 Continuous EEG studies, from patients with temporal lobe epilepsy, were reviewed by an expert reader.…”

“…12 A compressible layer of loose connective tissue fills the SG space, providing a safe site for chronic implantation of ventricular shunt reservoirs and valves, as well as Omaya reservoirs used for intraventricular chemotherapy administration. 13 Additionally, because SG tissue has elastic and absorptive properties, ventriculosubgaleal shunts provide temporary relief of elevated intracranial pressure for neonates with hydrocephalus. 14 Based on the stability and safety of these SG implants, we investigated the reliability and the potential viability of SGEEG for seizure identification and epilepsy management.…”

Ventricular Cerebrospinal Fluid Sampling in Pediatric Diffuse Midline Glioma Patients: Institutional Experience and Review of the Literature

“…CSF reservoirs were in place for up to 70.3 months in some cases, with reports of up to 280 IVC instillations per device ( Table 4). 42 infectious (8.5%) and 46 (9.3%) non-infectious reservoir related complications were reported, some occurring in the same patient (Table 4) (37)(38)(39)(40)(41)(42). The most common non-infectious reservoir-related complications included catheter migration and/or malfunction (n = 14), and CSF leak and/or wound dehiscence (n = 18).…”

Ventriculoperitoneal Shunts Equipped with On-Off Valves for Intraventricular Therapies in Patients with Communicating Hydrocephalus due to Leptomeningeal Metastases

“…In type (I), some valves can be switched on and off by pressing a button, while in type (II), the opening pressure can be changed with a specialized device. In the latter type, the opening pressure can be temporarily raised so high that the shunt should not drain cerebrospinal fluid, and therapeutics can be injected fairly reliably through the reservoir into the ventricles [ 8 , 9 , 10 ]. For the application of intrathecal therapies, those valves that can be switched on and off—type (I)—may be more useful.…”