Malfungsi shunt: dihubungkan Jumlah Sel dan Protein pada Analisis Cairan Serebrospinal Shunt Malfunction: Related to Protein Level and Cell Count in CSF Analysis.
Malfungsi shunt: dihubungkan Jumlah Sel dan Protein pada Analisis Cairan
Serebrospinal
Yunus M/Arifin M.Z.
Department of neurosurgery Padjadjaran University – Hasan Sadikin Hospital Bandung
Abstrak
Pendahuluan: VP-shunt merupakan suatu tindakan untuk mengatasi hydrosefalus dengan
berbagai penyebab, tetapi pemasangan vp shunt sering mengalami malfungsi karena jumlah
sel atau kadar protein yang tinggi. Penelitian ini bertujuan untuk mengetahui kadar protein
dan jumlah sel yang dapat mengakibatkan terjadinya malfungsi shunt.
Metode: penelitian dilakukan secara retrospektif dengan melihat data protein dan jumlah sel
LCS pasien malfungsi shunt yang dirawat di RSHS periode July 2009 sampai dengan periode
July 2011, kemudian dilakukan pengelompokan dan dibandingkan hasilnya.
Hasil: dari 21 kasus malfungsi VP shunt didapatkan 12 kasus pada pria, dan 9 kasus pada
wanita, rat-rata usia pasien 48 bulan dengan kejadian terbanyak pada usia 1 tahun, 2 tahun,
dan 13 tahun. Jumlah sel memiliki korelasi -0,605 dengan p=0,001. Sedangkan jumlah
protein memiliki korelasi -0,544 dengan korelasi p=0,001. Jumlah glukosa tidak sginifikan
dengan p=0,176. Jumlah sel > 144 dan jumlah Prootein > 200 secara signifikan berpengaruh
terhadap kejadian malfungsi shunt.
Kesimpulan: Terdapat peningkatan jumlah sel dan kadar protein pada cairan serebrospinal
pada kejadian malfungsi shunt. Jumlah sel > 144 dan jumlah protein LCS >200 berpengaruh
secara signifikan terhadap angka kejadian malfungsi shunt.
Kata Kunci: . Malfungsi Shunt. Hidrosefalus . Protein cairan serebrospinal . Sel cairan
serebrospinal
1
Shunt Malfunction: Related to Protein Level and Cell Count in CSF Analysis
Arifin M.Z.
Department of neurosurgery Padjadjaran University – Hasan Sadikin Hospital Bandung
Abstract
Introduction: VP-shunt as a management of hydrocephalus with various etiology, but the
placement frequently complicated by malfunction of the shunt. High levels of cell counts and
or protein in CSF usually found in those cases. Previous studies reported that high protein
level in CSF was not influence the occurence of shunt malfunction. This study aims to
determine protein levels and cell counts in shunt malfunction cases in our center.
Methods: The study was conducted retrospectively by looking at the data of protein and cell
count CSF shunt malfunction patients who were treated at RSHS July 2009 to July 2011
period, and then do the grouping and compared the results.
Results: We found 21 cases of VP shunt malfunction with 12 male and 9 female, the mean
age of cases was 48 months with the highest occurence at the first, second year of age and at
13 years old. Cell count and protein count are significant as factor with correlataion -0,605
and -0,544 with p=0,001 and 0,001,but glucose count is not significant with correlation
0,179.
Conclusion: There was an increased of cell count and protein levels in cerebrospinal fluid in
the incidence of VP shunt malfunction. Cel1 count > 144 and protein count > 200 are
significant as malfunction cause.
Key Words: . Shunt Malfunction . Hydrocephalus . Cerebrospinal fluid protein .
Cerebrospinal fluid cell
2
Introduction
Ventriculoperitoneal (VP) shunt is one of the commonest procedures in neurosurgical
practice as a threapy of hydrocephalus.1) Shunt Mechanical malfunction and infection are
the most
significant
problems
associated
with shunts
for
the
treatment
of
hydrocephalus.1,2) A significant problem encountered in shunt procedures is infection, with
infection rate ranging from 2 to 27%, often with poor outcome.1)
Death, intellectual and neurological deficit, and astronomical costs in terms of health
care funds and human suffering are the usual sequelae due to shunt malfunction.3) an
acceptable of CSF parameter to performed shunting was not found.4) For these reasons, the
management of shunt infection is of great concern to the neurosurgical community.
Because of that fact we report the characteristic of cerebrospinal fluid features
of
obstructing VP shunt in patient who underwent VP shunt.
Materials and Methods
A case control study during July 2009 until July 2011 was performed at Hasan Sadikin
Hospital to examined risk factor of shunt malfunction. Subject were patients who underwent
VP shunts and developed to malfunction shunt. Patients who underwent VP shunt and no
complaint in the same interval and characteristic with the cases as a control of the study.
Shunt malfunction is defined by any kind of shunt obstruction by all cases at proximal and or
distal of the shunt. for case grouph CSF was analys whent shunt malfunction was found, but
for control grouph, CSF analysis was peformed at the time of VP shunt implanted .
Risk factor that observed in this study were laboratory finding of CSF. Cell count, protein
count, and glucosa count were reevaluated to examined whether any correlation between
laboratory findings of CSF anlysis and shunt malfunction. Data were analysis with
correlation analysis to find a factor that influence shunt malfunction. Percentile 25, 50, and
75 was used to make a grouph of the study and Chi Square was using to examined which
grouph have a poor outcome and used as a predictor limit to shunt malfunction.
3
Results
During a 2 years observation we found 21 cases of VP shunt malfunction with 12 male and
9 female, the mean age of cases was 48 months with the highest occurence at the first,
second year of age and at 13 years old, and 21 cases as a control.
Correlation between analysis of CSF and shunt malfunction can be seen at table 1. Cell count
and protein count are significant as factor with correlation -0,605 and -0,544 with p=0,001
and 0,001, but glucose count is not significant with correlation 0,179.
Table 1. Correlation between CSF analysis and shunt malfunction
Item
Cell count
Protein
count
Gluc count
Malfunction
Remark
coeficient correlation
p
-0.605 0.001 significant
-0.544 0.001 significant
0.179 0.175 not
significant
Previous VP shunt placement indication was grouped into congenital (10 cases), infection (6
cases), and tumor (5 cases). There were 8 cases of proximal shunt malfunction, and 13 cases
of distal shunt malfunction.
Percentile 25, 50 and 75 of cell count can be seen in picture 1. We found percentile 25 is
7, percentile 50 is 51 and percetile 75 is 144 as we see at picture 1. The second and the third
grouph are significant with p value 0,001. We choosed percentile 75 as a predictor because
the objective of this study is to find critical count that can use as a predictor of shunt
malfunction
4
Percentile :
25=7
50= 51, p=0,000
75=144, p=0,001
Percentile 25, 50, and 75 of the protein count were 47, 79, 200. With p value of the third
group 0,001. So the percentile 75 is used as predictor count of shunt malfunction. This result
5
can be seen at picture no 2.dis
Percentile :
25=47, p=0,056
50= 79 p=0,000
75=200, p=0,001
Discussion
It is debatable when patient with hydrocephalus and high account of cell and protein can be
safely implanted VP shunt. Some report declare no relationship between cell and protein
count incorrrelation with shunt malfunction, but others have opposite arguement.
In our study Cell count and protein count was found to be correlated with shunt malfunction.
We found correlation 0,605 with signficancy 0.001 in cell count. This is a middle level of
correlation. After explored which grouph increased the risk of shunt malfunction, we found
cell count more than 144 is critical level to have shunt malfunction.
On protein, we found correlation 0.544 with significansy 0.001. We also try to found a
parameter to of protein count as a chriteria to decide when shunting can be performed. We
found protein count more than 200 is critical level to have shunt malfunction.
6
In our opinion, cell and protein have same effect on CSF. Increasing protein and cell count
increase viscocity of CSF . The high concentrations of CSF will make CSF flow slowly than
counterpart, in our opinion, this mechanism responsible for obstruction.
Conclusion
There was an increased of cell count and protein levels in cerebrospinal fluid in the incidence
of VP shunt malfunction. Cel1 count > 144 and protein count > 200 are significant as
malfunction cause. There for it may be usefull to base the timing of shunt insertion on CSF
parameters.
7
Referrences
1. Lakhsmi V, Sarguna P. Ventriculoperitoneal shunt. Indian Journal of Medical
Microbiology, (2006) 24 (1):52-4
2. Sekhar LN, Mossv J, Guthkelch N. Malfunctioning ventriculoperitoneal shunts
Clinical and pathological features. J Neurosurg 56:411-416, 1982
3. Walters BC, Hoffman HJ, Hendrick B, Humphreys P. Cerebrospinal fluid shunt
infection Influences on initial management and subsequent outcome, J Neurosurg
60:1014-1021, 1984.
4. Fulkerson DH, Vachrajani S, Bohnstedt BN, Patei N,Patel AJ, Fox BD, et all.
Analysis of the risk of shunt failure or infection related to cerebrospinal fluid cell
count, protein level, and glucose levels in low-birth-weight premature infants with
poshemorragic hydrocephalus. Journal of Neurosurgical Pediatrics 7:147-151,2011
8
Serebrospinal
Yunus M/Arifin M.Z.
Department of neurosurgery Padjadjaran University – Hasan Sadikin Hospital Bandung
Abstrak
Pendahuluan: VP-shunt merupakan suatu tindakan untuk mengatasi hydrosefalus dengan
berbagai penyebab, tetapi pemasangan vp shunt sering mengalami malfungsi karena jumlah
sel atau kadar protein yang tinggi. Penelitian ini bertujuan untuk mengetahui kadar protein
dan jumlah sel yang dapat mengakibatkan terjadinya malfungsi shunt.
Metode: penelitian dilakukan secara retrospektif dengan melihat data protein dan jumlah sel
LCS pasien malfungsi shunt yang dirawat di RSHS periode July 2009 sampai dengan periode
July 2011, kemudian dilakukan pengelompokan dan dibandingkan hasilnya.
Hasil: dari 21 kasus malfungsi VP shunt didapatkan 12 kasus pada pria, dan 9 kasus pada
wanita, rat-rata usia pasien 48 bulan dengan kejadian terbanyak pada usia 1 tahun, 2 tahun,
dan 13 tahun. Jumlah sel memiliki korelasi -0,605 dengan p=0,001. Sedangkan jumlah
protein memiliki korelasi -0,544 dengan korelasi p=0,001. Jumlah glukosa tidak sginifikan
dengan p=0,176. Jumlah sel > 144 dan jumlah Prootein > 200 secara signifikan berpengaruh
terhadap kejadian malfungsi shunt.
Kesimpulan: Terdapat peningkatan jumlah sel dan kadar protein pada cairan serebrospinal
pada kejadian malfungsi shunt. Jumlah sel > 144 dan jumlah protein LCS >200 berpengaruh
secara signifikan terhadap angka kejadian malfungsi shunt.
Kata Kunci: . Malfungsi Shunt. Hidrosefalus . Protein cairan serebrospinal . Sel cairan
serebrospinal
1
Shunt Malfunction: Related to Protein Level and Cell Count in CSF Analysis
Arifin M.Z.
Department of neurosurgery Padjadjaran University – Hasan Sadikin Hospital Bandung
Abstract
Introduction: VP-shunt as a management of hydrocephalus with various etiology, but the
placement frequently complicated by malfunction of the shunt. High levels of cell counts and
or protein in CSF usually found in those cases. Previous studies reported that high protein
level in CSF was not influence the occurence of shunt malfunction. This study aims to
determine protein levels and cell counts in shunt malfunction cases in our center.
Methods: The study was conducted retrospectively by looking at the data of protein and cell
count CSF shunt malfunction patients who were treated at RSHS July 2009 to July 2011
period, and then do the grouping and compared the results.
Results: We found 21 cases of VP shunt malfunction with 12 male and 9 female, the mean
age of cases was 48 months with the highest occurence at the first, second year of age and at
13 years old. Cell count and protein count are significant as factor with correlataion -0,605
and -0,544 with p=0,001 and 0,001,but glucose count is not significant with correlation
0,179.
Conclusion: There was an increased of cell count and protein levels in cerebrospinal fluid in
the incidence of VP shunt malfunction. Cel1 count > 144 and protein count > 200 are
significant as malfunction cause.
Key Words: . Shunt Malfunction . Hydrocephalus . Cerebrospinal fluid protein .
Cerebrospinal fluid cell
2
Introduction
Ventriculoperitoneal (VP) shunt is one of the commonest procedures in neurosurgical
practice as a threapy of hydrocephalus.1) Shunt Mechanical malfunction and infection are
the most
significant
problems
associated
with shunts
for
the
treatment
of
hydrocephalus.1,2) A significant problem encountered in shunt procedures is infection, with
infection rate ranging from 2 to 27%, often with poor outcome.1)
Death, intellectual and neurological deficit, and astronomical costs in terms of health
care funds and human suffering are the usual sequelae due to shunt malfunction.3) an
acceptable of CSF parameter to performed shunting was not found.4) For these reasons, the
management of shunt infection is of great concern to the neurosurgical community.
Because of that fact we report the characteristic of cerebrospinal fluid features
of
obstructing VP shunt in patient who underwent VP shunt.
Materials and Methods
A case control study during July 2009 until July 2011 was performed at Hasan Sadikin
Hospital to examined risk factor of shunt malfunction. Subject were patients who underwent
VP shunts and developed to malfunction shunt. Patients who underwent VP shunt and no
complaint in the same interval and characteristic with the cases as a control of the study.
Shunt malfunction is defined by any kind of shunt obstruction by all cases at proximal and or
distal of the shunt. for case grouph CSF was analys whent shunt malfunction was found, but
for control grouph, CSF analysis was peformed at the time of VP shunt implanted .
Risk factor that observed in this study were laboratory finding of CSF. Cell count, protein
count, and glucosa count were reevaluated to examined whether any correlation between
laboratory findings of CSF anlysis and shunt malfunction. Data were analysis with
correlation analysis to find a factor that influence shunt malfunction. Percentile 25, 50, and
75 was used to make a grouph of the study and Chi Square was using to examined which
grouph have a poor outcome and used as a predictor limit to shunt malfunction.
3
Results
During a 2 years observation we found 21 cases of VP shunt malfunction with 12 male and
9 female, the mean age of cases was 48 months with the highest occurence at the first,
second year of age and at 13 years old, and 21 cases as a control.
Correlation between analysis of CSF and shunt malfunction can be seen at table 1. Cell count
and protein count are significant as factor with correlation -0,605 and -0,544 with p=0,001
and 0,001, but glucose count is not significant with correlation 0,179.
Table 1. Correlation between CSF analysis and shunt malfunction
Item
Cell count
Protein
count
Gluc count
Malfunction
Remark
coeficient correlation
p
-0.605 0.001 significant
-0.544 0.001 significant
0.179 0.175 not
significant
Previous VP shunt placement indication was grouped into congenital (10 cases), infection (6
cases), and tumor (5 cases). There were 8 cases of proximal shunt malfunction, and 13 cases
of distal shunt malfunction.
Percentile 25, 50 and 75 of cell count can be seen in picture 1. We found percentile 25 is
7, percentile 50 is 51 and percetile 75 is 144 as we see at picture 1. The second and the third
grouph are significant with p value 0,001. We choosed percentile 75 as a predictor because
the objective of this study is to find critical count that can use as a predictor of shunt
malfunction
4
Percentile :
25=7
50= 51, p=0,000
75=144, p=0,001
Percentile 25, 50, and 75 of the protein count were 47, 79, 200. With p value of the third
group 0,001. So the percentile 75 is used as predictor count of shunt malfunction. This result
5
can be seen at picture no 2.dis
Percentile :
25=47, p=0,056
50= 79 p=0,000
75=200, p=0,001
Discussion
It is debatable when patient with hydrocephalus and high account of cell and protein can be
safely implanted VP shunt. Some report declare no relationship between cell and protein
count incorrrelation with shunt malfunction, but others have opposite arguement.
In our study Cell count and protein count was found to be correlated with shunt malfunction.
We found correlation 0,605 with signficancy 0.001 in cell count. This is a middle level of
correlation. After explored which grouph increased the risk of shunt malfunction, we found
cell count more than 144 is critical level to have shunt malfunction.
On protein, we found correlation 0.544 with significansy 0.001. We also try to found a
parameter to of protein count as a chriteria to decide when shunting can be performed. We
found protein count more than 200 is critical level to have shunt malfunction.
6
In our opinion, cell and protein have same effect on CSF. Increasing protein and cell count
increase viscocity of CSF . The high concentrations of CSF will make CSF flow slowly than
counterpart, in our opinion, this mechanism responsible for obstruction.
Conclusion
There was an increased of cell count and protein levels in cerebrospinal fluid in the incidence
of VP shunt malfunction. Cel1 count > 144 and protein count > 200 are significant as
malfunction cause. There for it may be usefull to base the timing of shunt insertion on CSF
parameters.
7
Referrences
1. Lakhsmi V, Sarguna P. Ventriculoperitoneal shunt. Indian Journal of Medical
Microbiology, (2006) 24 (1):52-4
2. Sekhar LN, Mossv J, Guthkelch N. Malfunctioning ventriculoperitoneal shunts
Clinical and pathological features. J Neurosurg 56:411-416, 1982
3. Walters BC, Hoffman HJ, Hendrick B, Humphreys P. Cerebrospinal fluid shunt
infection Influences on initial management and subsequent outcome, J Neurosurg
60:1014-1021, 1984.
4. Fulkerson DH, Vachrajani S, Bohnstedt BN, Patei N,Patel AJ, Fox BD, et all.
Analysis of the risk of shunt failure or infection related to cerebrospinal fluid cell
count, protein level, and glucose levels in low-birth-weight premature infants with
poshemorragic hydrocephalus. Journal of Neurosurgical Pediatrics 7:147-151,2011
8