Idiopathic normal pressure hydrocephalus(iNPH)is caused by impaired cerebrospinal fluid absorption in the elderly;it is a surgically treatable form of dementia.Gait disturbance,dementia,and urinary incontinence are th...Idiopathic normal pressure hydrocephalus(iNPH)is caused by impaired cerebrospinal fluid absorption in the elderly;it is a surgically treatable form of dementia.Gait disturbance,dementia,and urinary incontinence are the triad of signs for iNPH.In addition to these clinical findings,imaging studies show characteristic ventricular enlargement.High Evans Index and‘disproportionately enlarged subarachnoid hydrocephalus’are other well-known imaging findings of iNPH.If the tap test shows improved symptoms,shunt surgery is performed.The disease was first described by Hakim and Adams in 1965,followed by the publication of the first,second,and third editions of the guidelines in 2004,2012,and 2020,respectively.Recent studies signal the glymphatic system and classical cerebrospinal fluid(CSF)absorption from the dural lymphatics as aetiological mechanisms of CSF retention.Research is also underway on imaging test and biomarker developments for more precise diagnosis,shunting technique options with fewer sequelae and complications,and the influence of genetics.Particularly,the newly introduced‘suspected iNPH’in the third edition of the guidelines may be useful for earlier diagnosis.However,less well-studied areas remain,such as pharmacotherapy in non-operative indications and neurological findings other than the triadic signs.This review briefly presents previous research on these and future issues.展开更多
Objective: To assess the effectiveness and safety of lumboperitoneal shunt for treatment of post-traumatic hydrocephalus(PTH).Methods: A retrospective analysis of medical records of patients with lumboperitoneal shunt...Objective: To assess the effectiveness and safety of lumboperitoneal shunt for treatment of post-traumatic hydrocephalus(PTH).Methods: A retrospective analysis of medical records of patients with lumboperitoneal shunts admitted in Shanghai Tenth People's Hospital from January 2014 to March 2017 was done.Experience with lumboperitoneal shunt placement for PTH was reviewed.The diagnosis of PTH was based on ventricular enlargement with the Evans' index(EI>0.3) before shunt implantation.Patients were evaluated for improvements in Glasgow Coma Scale(GCS), Glasgow Outcome Scale(GOS), and EI after shunt placement.Results: Totally, the study included 34 PTH patients with the average age of 49.32 years(range: 9–67 years).The average follow-up period was(3.9±3.5) months.Before lumboperitoneal shunt, the GOS score was(4±1), the GCS score was(8.53±3.38), and the EI score was(0.40±0.08).After shunt implantation, the GOS score was(3±1), the GCS score was(10.29±3.15), and the EI score was(0.34±0.13), respectively(P<0.05).Before lumboperitoneal shunt, 24(70.58%) patients had a GOS score of 4(vegetative state), and 10(29.42%) patients had a GOS score of 3(severe disabled).After lumboperitoneal shunt, 18(52.94%) patients had improvement in GOS(11 patients improve from GOS 4 to GOS 3, 5 patients from GOS 3 to GOS 2 and 2 patients from GOS 3 to GOS 1), 22(64.71%) patients achieved improvement in their GCS(14 patients GCS improvements ≥2 and 8 patients GCS improvement=1), 21(61.76%) patients had EI improvement(18 patients with EI<0.3).There was no complication in this study.Conclusion: Lumboperitoneal shunt placement is safe and effective for PTH, and serious complications are not observed.展开更多
Trends of various intracranial pressure (ICP) parameters for high pressure hydrocephalus patients are utilized to detect various shunt faults in their early stages, as well as, to monitor the effect of such faults on ...Trends of various intracranial pressure (ICP) parameters for high pressure hydrocephalus patients are utilized to detect various shunt faults in their early stages, as well as, to monitor the effect of such faults on shunt performance. A method was proposed to predict the time required for ICP to be abnormal and for the valve to reach full blockage condition. Furthermore, an auto valve schedule updating method is proposed and used to temporarily deal with detected faults until the patient is checked up by his/her physician. The proposed algorithms were evaluated using numerical simulation.展开更多
Objective:To analyze the effect of ventriculoperitoneal shunt on the recovery of brain function in children with hydrocephalus.Methods:The clinical data of 40 children with hydrocephalus were retrospectively analyzed....Objective:To analyze the effect of ventriculoperitoneal shunt on the recovery of brain function in children with hydrocephalus.Methods:The clinical data of 40 children with hydrocephalus were retrospectively analyzed.Ventriculoperitoneal shunt was performed with 9003 shunt tube and P.S.Shunt tube,B.C.E.shunt tube.Electroencephalogram(EEG),and brain CT/MRI were performed before and after surgery,and postoperative follow-up was carried out to observe the therapeutic effect.Results:In this study,there were seven cases of intracranial injury,seven cases of congenital hydrocephalus,11 cases of ventricular end obstruction,three cases of abdominal end obstruction,nine cases complicated with bacterial infection,and 3 cases of shunt entering the scrotum.The prognosis of all the children was good,and there were no significant changes in eight cases.Conclusion:Ventriculoperitoneal shunt is effective in the treatment of children with hydrocephalus.展开更多
Objective To investigate the value of Codman Hakim pressure adjustable shunt in the treatment of hydrocephalus associated with congenital intracranial anomalous venous return. Methods 2 patients whose diagnosis were c...Objective To investigate the value of Codman Hakim pressure adjustable shunt in the treatment of hydrocephalus associated with congenital intracranial anomalous venous return. Methods 2 patients whose diagnosis were confirmed by CT,MRI,MRV and DSA and programmable ventriculoperitoneal shunting was given.展开更多
The objective was to measure the visual acuity (VA) of children with the diagnosis of hydrocephalus with or without peritoneal-ventricular shunt (PVS). A total of 55 children were included in the study (34 Female), wi...The objective was to measure the visual acuity (VA) of children with the diagnosis of hydrocephalus with or without peritoneal-ventricular shunt (PVS). A total of 55 children were included in the study (34 Female), with an age range of 0 to 291 weeks. The VA was measured by the sweep visual evoked potential technique. Of those with a PVS, in 31 the ventricular valve was inserted before 15 days after the diagnosis whereas in 14 the ventricular valve was inserted after 15 days. The sweep VEP was performed in all children, 95 exams (94%) were abnormal and only 6 were normal. There was a statistical difference in the VA between children with a PVS inserted before 15 days of the diagnosis and children with a PVS after 15 days (p = 0.038) or those without a shunt (p = 0.031). Children with no complications of the PVS had a better VA as compared to those with shunt complications (p < 0.001). In the group of children with complications, again those who had a shunt inserted be-fore 15 days had better VA results in com- parison to those in whom the shunt was inserted after 15 days (p = 0.029). No statistical difference in the VA was found between children without the PVS and with those in which the shunt was inserted after 15 days of the di-agnosis of hydrocephalus (p = 0.699). We conclude that the delayed insertion of the PVS may compromise the visual development of these children.展开更多
<b><span style="font-family:Verdana;">Object: </span></b><span style="font-family:""><span style="font-family:Verdana;">Incidence of Idiopathic ch...<b><span style="font-family:Verdana;">Object: </span></b><span style="font-family:""><span style="font-family:Verdana;">Incidence of Idiopathic chronic hydrocephalus of the adult (ICHA) is increasing in Guinea due to the aging of the population. The goal of this study was to describe its epidemiology, clinical presentation, and surgical outcome in a low-resource medical environment. </span><b><span style="font-family:Verdana;">Method: </span></b><span style="font-family:Verdana;">Sixteen patients operated for a probable ICHA were prospectively studied according to a uniform protocol</span></span><span style="font-family:""> </span><span style="font-family:""><span style="font-family:Verdana;">from June 2019 to December 2020. On computerized tomography, all operated patients had a clinical triad of gait disturbance, incontinence, dementia associated with ventriculomegaly, and transependymal edema. In addition, all patients underwent a single lumbar tap, improved clinically, and were subsequently offered a shunt consisting of a simple catheter in 37.5% and a non-adjustable high-pressure valve in 62.5%. </span><b><span style="font-family:Verdana;">Result: </span></b><span style="font-family:Verdana;">The mean age was 68.31 </span></span><span style="font-family:Verdana;">±</span><span style="font-family:""> </span><span style="font-family:Verdana;">10.4 (range 49</span><span style="font-family:""> </span><span style="font-family:Verdana;">-</span><span style="font-family:""> </span><span style="font-family:Verdana;">89). The sex ratio H/F was 1.67/1. Clinically, the most frequent comorbidity was a combination of hypertension and diabetes in 56.5% of cases.</span><span style="font-family:""> </span><span style="font-family:Verdana;">The mean time to diagnosis was 8.31 ± 2.75 months (range 3 - 14). The immediate postoperative mortality was 12.5% from a status epilepticus and pulmonary sepsis. In addition, we observed 2 cases of chronic subdural hematoma (12.5%) and 2 cases of shunt dysfunction</span><span style="font-family:""> </span><span style="font-family:Verdana;">(12.5%) in the first three months. The functional outcome was good in 23% of patients at one month (N</span><span style="font-family:""> </span><span style="font-family:Verdana;">=</span><span style="font-family:""> </span><span style="font-family:""><span style="font-family:Verdana;">13), 50% at three months (N = 10), and 87.5% at six months (N = 8). </span><b><span style="font-family:Verdana;">Conclusion: </span></b><span style="font-family:Verdana;">In carefully selected cases, the surgical outcome of ICHA in Guinea </span></span><span style="font-family:Verdana;">is</span><span style="font-family:Verdana;"> comparable to high-income countries. Efforts need to be put in helping patients get covered with universal insurance and generally promote Neurosurgery in the country to improve the quality of care.展开更多
Neonatal hydrocephalus can arise from a multitude of disturbances, among them congenital aqueductal stenosis, myelomeningocele or posthemorrhagic complications in preterm infants. Diagnostic work-up comprises transfon...Neonatal hydrocephalus can arise from a multitude of disturbances, among them congenital aqueductal stenosis, myelomeningocele or posthemorrhagic complications in preterm infants. Diagnostic work-up comprises transfontanellar ultrasonography, T2 weighted MRI and clinical assessment for rare inherited syndromes. Classification of hydrocephalus and treatment guidelines is based on detailed consensus statements. The recent evidence favors catheter-based cerebrospinal fluid diversion in children below 6 months, but emerging techniques such as neuroendoscopic lavage carry the potential to lower shunt insertion rates. More long-term study results will be needed to allow for individualized, multidisciplinary decision making. This article gives an overview regarding contemporary pathophysiological concepts, the latest consensus statements and most recent technical developments.展开更多
BACKGROUND Intra-gastric migration of the distal ventriculoperitoneal shunt(VPS)catheter clinically presenting with or without trans-oral extrusion is one of the rare complications of VPS catheter insertion.AIM To ide...BACKGROUND Intra-gastric migration of the distal ventriculoperitoneal shunt(VPS)catheter clinically presenting with or without trans-oral extrusion is one of the rare complications of VPS catheter insertion.AIM To identify the demographics,clinical presentation,clinical findings,and results of surgical therapy offered for the treatment of intra-gastric migration of the distal VPS catheter,clinically presented with or without trans-oral extrusion.METHODS An online search was performed for the extraction/retrieval of the published/available literature pertaining to the above-mentioned VPS complication.Manuscripts were searched from PubMed,PMC(PubMed Central),ResearchGate,and Google Scholar databases using various terminology relating to the VPS complications.The first case of migration of a VPS catheter into the stomach was reported in the year 1980,and the data were retrieved from 1980 to December 2022.Cases were categorized into two groups;Group A:Cases who had migration of the distal VPS catheter into the stomach and clinically presented with trans-oral extrusion of the same,and Group B:Cases who had migration of the distal VPS catheter into the stomach,but presented without trans-oral extrusion.RESULTS A total of n=46 cases(n=27;58.69%male,and n=19;41.3%females)were recruited for the systematic review.Group A included n=32,and Group B n=14 cases.Congenital hydrocephalus was the indication for the primary VPS insertion for approximately half of the(n=22)cases.Approximately sixty percent(n=27)of them were children≤5 years of age at the time of the diagnosis of the complication mentioned above.In seventy-two percent(n=33)cases,this complication was detected within 24 mo after the VPS insertion/last shunt revision.Clinical diagnosis was evident for the entire group A cases.Various diagnostic modalities were used to confirm the diagnosis for Group B cases.Various surgical procedures were offered for the management of the complication in n=43 cases of both Groups.In two instances,intra-gastric migration of the distal VPS catheter was detected during the autopsy.This review documented four deaths.CONCLUSION Intra-gastric migration of the peritoneal end of a VPS catheter is one of the rare complications of VPS catheter implantation done for the treatment of hydrocephalus across all age groups.It was more frequently reported in children,although also reported in adults and older people.A very high degree of clinical suspicion is required for the diagnosis of a case of an intra-gastric migration of the distal VPS catheter clinically presenting without transoral extrusion.展开更多
Laparoscopic technique was used to place peritonesl terminal tube incerebrospinal fluid shunt in six patients with hydrocephalus in our series.Three kinds ofmethods were introduced.The results showed that the laparosc...Laparoscopic technique was used to place peritonesl terminal tube incerebrospinal fluid shunt in six patients with hydrocephalus in our series.Three kinds ofmethods were introduced.The results showed that the laparoscopic fine trocar puncture andsubcutaneous fixation method was the most efficient one.This approach was simple,reliableand less time-consuming.No complications associated with the technique were encountered.展开更多
文摘Idiopathic normal pressure hydrocephalus(iNPH)is caused by impaired cerebrospinal fluid absorption in the elderly;it is a surgically treatable form of dementia.Gait disturbance,dementia,and urinary incontinence are the triad of signs for iNPH.In addition to these clinical findings,imaging studies show characteristic ventricular enlargement.High Evans Index and‘disproportionately enlarged subarachnoid hydrocephalus’are other well-known imaging findings of iNPH.If the tap test shows improved symptoms,shunt surgery is performed.The disease was first described by Hakim and Adams in 1965,followed by the publication of the first,second,and third editions of the guidelines in 2004,2012,and 2020,respectively.Recent studies signal the glymphatic system and classical cerebrospinal fluid(CSF)absorption from the dural lymphatics as aetiological mechanisms of CSF retention.Research is also underway on imaging test and biomarker developments for more precise diagnosis,shunting technique options with fewer sequelae and complications,and the influence of genetics.Particularly,the newly introduced‘suspected iNPH’in the third edition of the guidelines may be useful for earlier diagnosis.However,less well-studied areas remain,such as pharmacotherapy in non-operative indications and neurological findings other than the triadic signs.This review briefly presents previous research on these and future issues.
文摘Objective: To assess the effectiveness and safety of lumboperitoneal shunt for treatment of post-traumatic hydrocephalus(PTH).Methods: A retrospective analysis of medical records of patients with lumboperitoneal shunts admitted in Shanghai Tenth People's Hospital from January 2014 to March 2017 was done.Experience with lumboperitoneal shunt placement for PTH was reviewed.The diagnosis of PTH was based on ventricular enlargement with the Evans' index(EI>0.3) before shunt implantation.Patients were evaluated for improvements in Glasgow Coma Scale(GCS), Glasgow Outcome Scale(GOS), and EI after shunt placement.Results: Totally, the study included 34 PTH patients with the average age of 49.32 years(range: 9–67 years).The average follow-up period was(3.9±3.5) months.Before lumboperitoneal shunt, the GOS score was(4±1), the GCS score was(8.53±3.38), and the EI score was(0.40±0.08).After shunt implantation, the GOS score was(3±1), the GCS score was(10.29±3.15), and the EI score was(0.34±0.13), respectively(P<0.05).Before lumboperitoneal shunt, 24(70.58%) patients had a GOS score of 4(vegetative state), and 10(29.42%) patients had a GOS score of 3(severe disabled).After lumboperitoneal shunt, 18(52.94%) patients had improvement in GOS(11 patients improve from GOS 4 to GOS 3, 5 patients from GOS 3 to GOS 2 and 2 patients from GOS 3 to GOS 1), 22(64.71%) patients achieved improvement in their GCS(14 patients GCS improvements ≥2 and 8 patients GCS improvement=1), 21(61.76%) patients had EI improvement(18 patients with EI<0.3).There was no complication in this study.Conclusion: Lumboperitoneal shunt placement is safe and effective for PTH, and serious complications are not observed.
文摘Trends of various intracranial pressure (ICP) parameters for high pressure hydrocephalus patients are utilized to detect various shunt faults in their early stages, as well as, to monitor the effect of such faults on shunt performance. A method was proposed to predict the time required for ICP to be abnormal and for the valve to reach full blockage condition. Furthermore, an auto valve schedule updating method is proposed and used to temporarily deal with detected faults until the patient is checked up by his/her physician. The proposed algorithms were evaluated using numerical simulation.
文摘Objective:To analyze the effect of ventriculoperitoneal shunt on the recovery of brain function in children with hydrocephalus.Methods:The clinical data of 40 children with hydrocephalus were retrospectively analyzed.Ventriculoperitoneal shunt was performed with 9003 shunt tube and P.S.Shunt tube,B.C.E.shunt tube.Electroencephalogram(EEG),and brain CT/MRI were performed before and after surgery,and postoperative follow-up was carried out to observe the therapeutic effect.Results:In this study,there were seven cases of intracranial injury,seven cases of congenital hydrocephalus,11 cases of ventricular end obstruction,three cases of abdominal end obstruction,nine cases complicated with bacterial infection,and 3 cases of shunt entering the scrotum.The prognosis of all the children was good,and there were no significant changes in eight cases.Conclusion:Ventriculoperitoneal shunt is effective in the treatment of children with hydrocephalus.
文摘Objective To investigate the value of Codman Hakim pressure adjustable shunt in the treatment of hydrocephalus associated with congenital intracranial anomalous venous return. Methods 2 patients whose diagnosis were confirmed by CT,MRI,MRV and DSA and programmable ventriculoperitoneal shunting was given.
基金supported by grants to MFC from CNPq 401153/2009-6 Ciencias Humanas.MFC is CNPq research fellow.
文摘The objective was to measure the visual acuity (VA) of children with the diagnosis of hydrocephalus with or without peritoneal-ventricular shunt (PVS). A total of 55 children were included in the study (34 Female), with an age range of 0 to 291 weeks. The VA was measured by the sweep visual evoked potential technique. Of those with a PVS, in 31 the ventricular valve was inserted before 15 days after the diagnosis whereas in 14 the ventricular valve was inserted after 15 days. The sweep VEP was performed in all children, 95 exams (94%) were abnormal and only 6 were normal. There was a statistical difference in the VA between children with a PVS inserted before 15 days of the diagnosis and children with a PVS after 15 days (p = 0.038) or those without a shunt (p = 0.031). Children with no complications of the PVS had a better VA as compared to those with shunt complications (p < 0.001). In the group of children with complications, again those who had a shunt inserted be-fore 15 days had better VA results in com- parison to those in whom the shunt was inserted after 15 days (p = 0.029). No statistical difference in the VA was found between children without the PVS and with those in which the shunt was inserted after 15 days of the di-agnosis of hydrocephalus (p = 0.699). We conclude that the delayed insertion of the PVS may compromise the visual development of these children.
文摘<b><span style="font-family:Verdana;">Object: </span></b><span style="font-family:""><span style="font-family:Verdana;">Incidence of Idiopathic chronic hydrocephalus of the adult (ICHA) is increasing in Guinea due to the aging of the population. The goal of this study was to describe its epidemiology, clinical presentation, and surgical outcome in a low-resource medical environment. </span><b><span style="font-family:Verdana;">Method: </span></b><span style="font-family:Verdana;">Sixteen patients operated for a probable ICHA were prospectively studied according to a uniform protocol</span></span><span style="font-family:""> </span><span style="font-family:""><span style="font-family:Verdana;">from June 2019 to December 2020. On computerized tomography, all operated patients had a clinical triad of gait disturbance, incontinence, dementia associated with ventriculomegaly, and transependymal edema. In addition, all patients underwent a single lumbar tap, improved clinically, and were subsequently offered a shunt consisting of a simple catheter in 37.5% and a non-adjustable high-pressure valve in 62.5%. </span><b><span style="font-family:Verdana;">Result: </span></b><span style="font-family:Verdana;">The mean age was 68.31 </span></span><span style="font-family:Verdana;">±</span><span style="font-family:""> </span><span style="font-family:Verdana;">10.4 (range 49</span><span style="font-family:""> </span><span style="font-family:Verdana;">-</span><span style="font-family:""> </span><span style="font-family:Verdana;">89). The sex ratio H/F was 1.67/1. Clinically, the most frequent comorbidity was a combination of hypertension and diabetes in 56.5% of cases.</span><span style="font-family:""> </span><span style="font-family:Verdana;">The mean time to diagnosis was 8.31 ± 2.75 months (range 3 - 14). The immediate postoperative mortality was 12.5% from a status epilepticus and pulmonary sepsis. In addition, we observed 2 cases of chronic subdural hematoma (12.5%) and 2 cases of shunt dysfunction</span><span style="font-family:""> </span><span style="font-family:Verdana;">(12.5%) in the first three months. The functional outcome was good in 23% of patients at one month (N</span><span style="font-family:""> </span><span style="font-family:Verdana;">=</span><span style="font-family:""> </span><span style="font-family:""><span style="font-family:Verdana;">13), 50% at three months (N = 10), and 87.5% at six months (N = 8). </span><b><span style="font-family:Verdana;">Conclusion: </span></b><span style="font-family:Verdana;">In carefully selected cases, the surgical outcome of ICHA in Guinea </span></span><span style="font-family:Verdana;">is</span><span style="font-family:Verdana;"> comparable to high-income countries. Efforts need to be put in helping patients get covered with universal insurance and generally promote Neurosurgery in the country to improve the quality of care.
文摘Neonatal hydrocephalus can arise from a multitude of disturbances, among them congenital aqueductal stenosis, myelomeningocele or posthemorrhagic complications in preterm infants. Diagnostic work-up comprises transfontanellar ultrasonography, T2 weighted MRI and clinical assessment for rare inherited syndromes. Classification of hydrocephalus and treatment guidelines is based on detailed consensus statements. The recent evidence favors catheter-based cerebrospinal fluid diversion in children below 6 months, but emerging techniques such as neuroendoscopic lavage carry the potential to lower shunt insertion rates. More long-term study results will be needed to allow for individualized, multidisciplinary decision making. This article gives an overview regarding contemporary pathophysiological concepts, the latest consensus statements and most recent technical developments.
文摘BACKGROUND Intra-gastric migration of the distal ventriculoperitoneal shunt(VPS)catheter clinically presenting with or without trans-oral extrusion is one of the rare complications of VPS catheter insertion.AIM To identify the demographics,clinical presentation,clinical findings,and results of surgical therapy offered for the treatment of intra-gastric migration of the distal VPS catheter,clinically presented with or without trans-oral extrusion.METHODS An online search was performed for the extraction/retrieval of the published/available literature pertaining to the above-mentioned VPS complication.Manuscripts were searched from PubMed,PMC(PubMed Central),ResearchGate,and Google Scholar databases using various terminology relating to the VPS complications.The first case of migration of a VPS catheter into the stomach was reported in the year 1980,and the data were retrieved from 1980 to December 2022.Cases were categorized into two groups;Group A:Cases who had migration of the distal VPS catheter into the stomach and clinically presented with trans-oral extrusion of the same,and Group B:Cases who had migration of the distal VPS catheter into the stomach,but presented without trans-oral extrusion.RESULTS A total of n=46 cases(n=27;58.69%male,and n=19;41.3%females)were recruited for the systematic review.Group A included n=32,and Group B n=14 cases.Congenital hydrocephalus was the indication for the primary VPS insertion for approximately half of the(n=22)cases.Approximately sixty percent(n=27)of them were children≤5 years of age at the time of the diagnosis of the complication mentioned above.In seventy-two percent(n=33)cases,this complication was detected within 24 mo after the VPS insertion/last shunt revision.Clinical diagnosis was evident for the entire group A cases.Various diagnostic modalities were used to confirm the diagnosis for Group B cases.Various surgical procedures were offered for the management of the complication in n=43 cases of both Groups.In two instances,intra-gastric migration of the distal VPS catheter was detected during the autopsy.This review documented four deaths.CONCLUSION Intra-gastric migration of the peritoneal end of a VPS catheter is one of the rare complications of VPS catheter implantation done for the treatment of hydrocephalus across all age groups.It was more frequently reported in children,although also reported in adults and older people.A very high degree of clinical suspicion is required for the diagnosis of a case of an intra-gastric migration of the distal VPS catheter clinically presenting without transoral extrusion.
文摘Laparoscopic technique was used to place peritonesl terminal tube incerebrospinal fluid shunt in six patients with hydrocephalus in our series.Three kinds ofmethods were introduced.The results showed that the laparoscopic fine trocar puncture andsubcutaneous fixation method was the most efficient one.This approach was simple,reliableand less time-consuming.No complications associated with the technique were encountered.