title: 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.
  
  
  METHODS
  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.
authors.affiliation: Department of Surgery, Division of Neurosurgery, University of Arizona, 1501 N. Campbell Ave., Tucson, Arizona, USA.
authors.forename: Sheri K
authors.initials: SK
authors.lastname: Palejwala
authors.affiliation: Department of Surgery, Division of Neurosurgery, University of Arizona, 1501 N. Campbell Ave., Tucson, Arizona, USA.
authors.forename: David A
authors.initials: DA
authors.lastname: Stidd
authors.affiliation: Department of Surgery, Division of Neurosurgery, University of Arizona, 1501 N. Campbell Ave., Tucson, Arizona, USA.
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Skoch
authors.affiliation: Department of Pediatrics, Division of Pediatric Oncology, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, Ohio, USA.
authors.forename: Puja
authors.initials: P
authors.lastname: Gupta
authors.affiliation: Department of Surgery, Division of Neurosurgery, University of Arizona, 1501 N. Campbell Ave., Tucson, Arizona, USA.
authors.forename: G Michael
authors.initials: GM
authors.lastname: Lemole
authors.affiliation: Department of Surgery, Division of Neurosurgery, University of Arizona, 1501 N. Campbell Ave., Tucson, Arizona, USA.
authors.forename: Martin E
authors.initials: ME
authors.lastname: Weinand
keywords: Chemotherapy; hydrocephalus; intracerebral hemorrhage; pediatric neurosurgery; ventriculoperitoneal shunt