Subduro-peritoneal shunts in the management of subdural collection related to ruptured intracranial arachnoid cysts
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LETTER TO THE EDITOR
Subduro-peritoneal shunts in the management of subdural collection related to ruptured intracranial arachnoid cysts Marco Ceraudo 1
&
Alessandro Prior 1
Received: 20 October 2020 / Accepted: 29 October 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Dear Editor: We read with great interest the paper of Tinois et al. entitled “Ruptured intracranial arachnoid cysts in the subdural space: evaluation of subduro-peritoneal shunts in a pediatric population” [1]. In the paper, the authors affirmed that medium-pressure subduro-peritoneal shunts should be considered as part of the arsenal in the surgical treatment of symptomatic ruptured arachnoid cyst in the subdural space. The procedure is described as simple with very low morbidity, permitting rapid improvement of symptoms. Rupture of arachnoid cysts is a rare but well-recognized event [2] but conversely, shunt-related risk of overdrainage is related to serious short- and long-term complications, especially in paediatric population [3, 4]. Additionally, the risk of exposing the patient to a condition of shunt dependency is consistent [5, 6]. Considering these issues, the authors strongly recommended avoiding devices that might favour these conditions such as low-pressure shunts. In their study on 54 paediatric patients, Sandberg et al. found that fluid from arachnoid cysts has a chemical composition similar to that of CSF, but some of them have significantly elevated protein levels [7]. These data, associated with the results obtained by Gorelick et al., suggest that increased protein levels in CSF can lead to a significant decrease in resistance to flow in new shunt systems. Significant changes in flow rates in differential pressure valves may increase with highly elevated protein levels, and this variability is potentially attenuated by activating a narrow-lumen high-resistance
pathway as used with a so-called SiphonGuard (Codman by Integra) [8]. We agree with the authors’ advices, and we think that subduro-peritoneal shunts with atlas valves should be considered a valid solution because of their recognized tolerance to hyperproteic fluids [9]. The choice of fixed differential pressure valves carries the limitation that valve types are limited. Conversely, the use of programmable valves enables clinicians to calibrate a valve’s opening pressure to meet their patients’ drainage needs. Programmable valves also allow the progressive increase in opening pressure until their complete closure. They also permit to demonstrate the autonomy of reabsorption or recurrence of the subdural collection before the onset of shunt dependency. It should be also underlined that children under 1 year of age may show immaturity in CSF resorption thus prolonging the permanent use of the shunt and necessitating slow but progressive valve opening pressure modification. In case a not programmable valve has been chosen and the clinician considers the shunt removal as indicated, a transitory shunt ligature should be considered.
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