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John R. W. Kestle, Jay Riva-Cambrin, John C. Wellons III, Abhaya V. Kulkarni, William E. Whitehead, Marion L. Walker, W. Jerry Oakes, James M. Drake, Thomas G. Luerssen, Tamara D. Simon and Richard Holubkov

I nfection of ventriculoperitoneal shunts continues to be a source of morbidity for children with hydrocephalus and a frustrating problem for clinicians. In large databases the procedural infection rate has been reported as approximately 8%–10%. 7 , 8 , 14 Shunt infection is an important contributor to the cost of care in pediatric hydrocephalus. 2 Treatment of infection requires hospital admission, surgical removal of the device, inpatient intravenous antibiotic therapy for a variable period of time, 1 , 16 and implantation of a new shunt system

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Tamara D. Simon, Matthew P. Kronman, Kathryn B. Whitlock, Nancy E. Gove, Nicole Mayer-Hamblett, Samuel R. Browd, D. Douglas Cochrane, Richard Holubkov, Abhaya V. Kulkarni, Marcie Langley, David D. Limbrick Jr., Thomas G. Luerssen, W. Jerry Oakes, Jay Riva-Cambrin, Curtis Rozzelle, Chevis Shannon, Mandeep Tamber, John C. Wellons III, William E. Whitehead and John R. W. Kestle

W hile lifesaving and the mainstay of hydrocephalus treatment, 15 CSF shunts can cause new and chronic surgical and medical problems in children with hydrocephalus. Mechanical malfunction is frequent, with 40% of shunts requiring surgical revision within 2 years. 22 With each additional CSF shunt surgery, the risk of CSF shunt infection increases. 2 , 25 , 49 CSF shunt infection rates range from 0% to 35% per surgery, 5 , 12 , 20 , 24 , 25 , 28 , 30 , 31 , 33 , 34 , 36 , 56 with an average of 6%–8%. 18 , 19 CSF shunt reinfection after an initial infection

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Tamara D. Simon, Matthew P. Kronman, Kathryn B. Whitlock, Samuel R. Browd, Richard Holubkov, John R. W. Kestle, Abhaya V. Kulkarni, Marcie Langley, David D. Limbrick Jr., Thomas G. Luerssen, W. Jerry Oakes, Jay Riva-Cambrin, Curtis Rozzelle, Chevis N. Shannon, Mandeep Tamber, John C. Wellons III, William E. Whitehead and Nicole Mayer-Hamblett

W hile CSF shunts are life-saving and the mainstay of hydrocephalus treatment, 6 they are associated with new and chronic surgical and medical problems for children with hydrocephalus. These problems include mechanical malfunction requiring surgical revision 11 as well as CSF shunt infection. 1 , 12 , 23 While numerous review articles have been written, 3–6 , 18 until recently no organization in the US or elsewhere had published guidelines for CSF shunt infection management. However, the Infectious Diseases Society of America (IDSA), within the 2004

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R. Shane Tubbs, John C. Wellons III, Jeffrey P. Blount and W. Jerry Oakes

T here are many causes for the dysfunction of CSF diversionary systems. Of these causes the more common ones include obstruction, fracture, or infection of the system. Many have found distal infections primarily of the peritoneum to cause transient absorptive dysfunction of this accepting cavity. To our knowledge, no author has discussed the possibility of a subperitoneal infection, such as urinary bladder infection, as a potential cause of distal malabsorptive complications for VP shunts. Case Reports Three children (two girls and one boy), 9 to 15

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R. Shane Tubbs, John C. Wellons III, Jeffrey P. Blount and W. Jerry Oakes

T here are many causes for the dysfunction of CSF diversionary systems. Of these causes the more common ones include obstruction, fracture, or infection of the system. Many have found distal infections primarily of the peritoneum to cause transient absorptive dysfunction of this accepting cavity. To our knowledge, no author has discussed the possibility of a subperitoneal infection, such as urinary bladder infection, as a potential cause of distal malabsorptive complications for VP shunts. Case Reports Three children (two girls and one boy), 9 to 15

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Cuong J. Bui, R. Shane Tubbs, Gigi Pate, Traci Morgan, Douglas C. Barnhart, Leslie Acakpo-Satchivi, John C. Wellons III, W. Jerry Oakes and Jeffrey P. Blount

I nfection is a significant cause of morbidity and death for children with CSF shunts. Reported shunt infection rates in this cohort vary greatly (1.5 to 38%), with an average rate of 8 to 10%. 11 , 13 In infants and neonates, however, significantly higher rates have been reported (approximately 20%). Some investigators have found that the highest risk of postshunt infection occurs within 6 months of shunt insertion or revision. Additionally, many infants with shunted hydrocephalus, particularly premature neonates with hydrocephalus secondary to

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John R. W. Kestle, Richard Holubkov, D. Douglas Cochrane, Abhaya V. Kulkarni, David D. Limbrick Jr., Thomas G. Luerssen, W. Jerry Oakes, Jay Riva-Cambrin, Curtis Rozzelle, Tamara D. Simon, Marion L. Walker, John C. Wellons III, Samuel R. Browd, James M. Drake, Chevis N. Shannon, Mandeep S. Tamber, William E. Whitehead and The Hydrocephalus Clinical Research Network

I nfection continues to be a common complication of CSF shunts for children with hydrocephalus, and there are ongoing efforts to identify methods or devices that may reduce this risk. Quality-improvement research has suggested that standardized protocols may reduce device-related infection in a number of areas. 1 , 3 , 11 The Hydrocephalus Clinical Research Network (HCRN) has used this approach to minimize shunt infection rates since 2007. A protocol was developed using the available literature that included 11 steps aimed at reducing infection, such as

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Blake Pearson, Cuong J. Bui, R. Shane Tubbs and John C. Wellons III

with a CT scan of the chest; Fig. 1B–D ). This was treated as a shunt infection, with removal of the device and placement of a ventriculostomy, and intravenous antibiotics were administered prior to shunt reinsertion. The area of edema resolved after surgery. After ventriculostomy drainage, a ventriculopleural shunt was inserted into the contralateral pleural space, with good results at 1 year. Possible mechanisms leading to this migration included the dynamic actions of the heart or diaphragm, which were near the site of chest wall reentry, or it is possible that

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Nicholas Ettinger, Matthew Pearson, Fred S. Lamb and John C. Wellons III

pediatric ICU for close monitoring and treatment. Presenting symptoms can have significant overlap with other important clinical entities such as effects from a mass lesion or infection. Although this patient's form of PRES has been documented in adults, 3 it has been very rarely described to occur in children. 8 This case illustrates how it is essential for pediatric intensivists and pediatric neurosurgeons to be aware of the spectrum of clinical presentation of PRES and to keep this disease on their differentials. Case Report History A 13-year-old, 30-kg

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Michael C. Dewan, Jaims Lim, Chevis N. Shannon and John C. Wellons III

whenever a repeat intervention for hydrocephalus was reported, including repeat ETV or VPS insertion (for primary ETV), or VPS revision or ETV (for a primary VPS). Complications from each source article were tabulated across studies and included infection, shunt malposition, aborted ETV, ependymal vascular injury, extraaxial hemorrhagic or CSF collection, ocular palsy, and hypothalamic disturbance. Studies were excluded for any of the following reasons: adult and pediatric patients were indistinguishable, PFBTs were indistinguishable from other tumor types/locations, and