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Concept: Cerebral shunt

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OBJECTIVE: Ventriculoperitoneal (VP) shunt surgery is the predominant mode of therapy for patients with hydrocephalus. However, it has potential complications that may require multiple surgical procedures during a patient’s lifetime. The objective of this study is to review our long-term experience and evaluate the risk factors for VP shunt failure after initial shunt surgery and after subsequent revisions. METHODS: Patients who underwent VP shunt surgery for hydrocephalus were included. Medical charts, operative reports, imaging studies, and clinical follow-up evaluations were reviewed and analyzed retrospectively. RESULTS: A total of 1015 patients with the median age of 41.6 (range, 0 - 90.3) years at the time of VP shunt surgery were included. The mean and median follow up was 9.2 and 6.5 years, respectively. Adult patients (≥ 17 years) accounted for 70.0% of the patients. The overall shunt failure rate requiring shunt revision(s) was 46.3% and the majority of shunt revisions occurred during the first 6 months after shunt placement. The shunt revision rate was significantly higher in pediatric (< 17 years) than in adult (> 17 years) patients (78.2% vs.32.5%, P < 0.001). Age at the time of shunt surgery, prior treatments to shunt surgery, etiology of hydrocephalus, and hydrocephalus type were independently associated with the incidence of shunt revision. Age at shunt placement and gender were significantly associated with multiple shunt revisions. Among population with at least one shunt revision, pediatric patients had significantly lower shunt survival rate and shorter median time to subsequent shunt revision than the adult (> 17 years) patients; male patients had higher odds for multiple revisions than females. CONCLUSION: The findings of the study indicate that age at shunt placement, etiology of hydrocephalus, type of hydrocephalus, and prior treatments before shunt surgery were independently significantly associated with the shunt survival. Prospective controlled studies are required to address the observed associations between the risk factors and incidence of shunt revisions in these patients.

Concepts: Time, Medicine, Surgery, Median, Physician, Arithmetic mean, Hydrocephalus, Cerebral shunt

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PURPOSE: Management of hydrocephalus with insertion of ventriculoperitoneal (VP) shunt is associated with significant complications in both adult and pediatric patients. These may be more common in developing countries due to poor economic conditions and a dearth of available resources. We report a 6 years' experience with VP shunt insertion in pediatric patients from a developing country, focusing particularly on factors affecting shunt failure. METHODS: Patients aged below 15 years, who had undergone insertion of VP shunts for hydrocephalus during the years 2006 to 2011, were included. A retrospective analysis of shunt survival was performed using Kaplan-Meier curves and Logrank (Cox-Mantel) test. RESULTS: Among the total 113 patients, the most common etiologies of hydrocephalus were congenital hydrocephalus (19.5 %), brain tumors (14.2 %), and postcranial surgery (13.3 %). Overall shunt failure at a mean follow-up of 11 months was 23 % with the median time to first shunt failure being 68 days. Shunt survival was worse in patients with meningitis (p = 0.024), aqueductal stenosis (p = 0.008), postcranial surgery hydrocephalus (p = 0.006), Caesarean mode of delivery (p = 0.036), congenital abnormalities (p = 0.031), and a past history of surgical excision of mass lesion (p = 0.044).Frequency of shunt failure was also significantly affected by the location of brain tumor (p = 0.015) and prematurity (p = 0.015). CONCLUSION: Premature infants still have a higher rate of shunt failure. Patients with meningitis, aqueductal stenosis, postcranial surgery hydrocephalus, congenital abnormalities, and a past history of surgical excision of mass lesion may have early shunt failure. However, the frequency of shunt failure that we observed (23 %) was much lower than that quoted earlier in the literature and this may be a consequence of rigorous periodic evaluation of patients with VP shunt in situ.

Concepts: Medicine, Cancer, Oncology, Surgery, Intracranial pressure, Brain tumor, Hydrocephalus, Cerebral shunt

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Object Ventriculoperitoneal (VP) shunt placement remains the mainstay treatment for pediatric hydrocephalus. These devices have a relatively high complication and failure rate, often requiring multiple revisions. The authors present a single institution’s experience of pediatric patients treated with VP shunts. With an average follow-up time of 20 years, this study is among the longest reports of VP shunt revision in the literature to date. Hydrocephalus origins, shunt revision rates, and causes of shunt failure are described. Patients who underwent their first shunt revision more than 10 years after initial shunt placement were also explored. Methods A retrospective chart review was performed on all pediatric patients who underwent VP shunt placement from January 1990 through November 1996 at the University of Rochester Medical Center. Only patients who had at least 15 years of follow-up since their initial shunting procedure were included. Results A total of 234 procedures were performed on 64 patients, with a mean follow-up of 19.9 years. Patients ranged from a few days to 17.2 years old when they received their original shunt, with a median age of 4 months; 84.5% of the patients required 1 or more shunt revisions and 4.7% required 10 or more. Congenital defects, Chiari Type II malformations, tumors, and intraventricular hemorrhage were the most common causes of hydrocephalus. Overall, patients averaged 2.66 revisions, with proximal (27%) and distal (15%) catheter occlusion, disconnection (11%), and infection (9%) comprising the most common reasons for shunt malfunction. Notably, 12.5% of patients did not require their first shunt revision until more than 10 years after initial device placement, a previously undescribed finding due to the short follow-up duration in previous studies. Conclusions This long-term retrospective analysis of pediatric VP shunt placement revealed a relatively high rate of complications with need for shunt revision as late as 17 years after initial placement. Catheter occlusion represented a significant percentage of shunt failures. Cerebrospinal fluid shunting has a propensity for mechanical failure and patients with VP shunts should receive follow-up through the transition to adulthood.

Concepts: Intracranial pressure, Cerebrospinal fluid, Failure, Congenital disorder, Hydrocephalus, Congenital disorders, Arnold-Chiari malformation, Cerebral shunt

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The long-term maintenance of ventriculoperitoneal (VP) shunt function depends on the correct placement of the catheter tip in the lateral ventricle. The relationship between the location of the ventricular catheter tip and VP shunt function was analyzed in 52 patients. The location of the ventricular catheter tip was classified into one of the following five groups: (i) Group A - superior to the foramen of Monro; (ii) Group B - in the center of the lateral ventricle body; (iii) Group C - in the third ventricle; (iv) Group D - contacting the ventricle wall; and (v) Group E - in the septum pellucidum. VP shunt function was defined as well controlled hydrocephalus when the Evan’s ratio of the ventricular size was < 0.3. The VP shunt functioned well in 14 of 52 patients (26.9%), the shunt valve pressure was incorrectly set in 21 (40.4%), and irreversible shunt malfunction was identified in 17 (32.7%). Among the 14 patients with a well-functioning shunt, 13 were in Groups A or B with an odds ratio (OR) of 17.875 (p<0.05). In the 17 irreversible shunt malfunctions, 13 were identified in Groups C, D, or E with an OR of 0.123 (p<0.05). Long term VP shunt function or failure due to irreversible malfunction is directly influenced by the position of the ventricular catheter tip. Ideal points for positioning the ventricular catheter tip are superior to the foramen of Monro and in the center of the lateral ventricle body. Early shunt revision may be required for patients in whom the catheter tip contacts the ventricle wall or is located in the septum pellucidum.

Concepts: Cerebrospinal fluid, Term, Hydrocephalus, Catheter, Ventricular system, Group B, Fourth ventricle, Cerebral shunt

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Prior research has examined predictors of shunt failure in children with hydrocephalus and concluded that the majority of shunts do not survive long-term. However, risk factors such as etiology, birth weight, and gestational age may vary across institutions and populations. We sought to identify the social, clinical, and neonatal factors associated with initial ventriculoperitoneal (VP) shunt failure in the intraventricular hemorrhage (IVH) patient population and the patient population with an etiology other than IVH (non-IVH).

Concepts: Pregnancy, Fetus, Demography, Population, Obstetrics, Sociology, Hydrocephalus, Cerebral shunt

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OBJECT In ventriculoperitoneal (VP) shunt surgery, laparoscopic assistance can be used for placement of the peritoneal catheter. Until now, the efficacy of laparoscopic shunt placement has been investigated only in retrospective and nonrandomized prospective studies, which have reported decreased distal shunt dysfunction rates in patients undergoing laparascopic placement compared with mini-laparotomy cohorts. In this randomized controlled trial the authors compared rates of shunt failure in patients who underwent laparoscopic surgery for peritoneal catheter placement with rates in patients who underwent traditional mini-laparotomy. METHODS One hundred twenty patients scheduled for VP shunt surgery were randomized to laparoscopic surgery or mini-laparotomy for insertion of the peritoneal catheter. The primary endpoint was the rate of overall shunt complication or failure within the first 12 months after surgery. Secondary endpoints were distal shunt failure, overall complication/ failure, duration of surgery and hospitalization, and morbidity. RESULTS The overall shunt complication/failure rate was 15% (9 of 60 cases) in the laparoscopic group and 18.3% (11 of 60 cases) in the mini-laparotomy group (p = 0.404). Patients in the laparoscopic group had no distal shunt failures; in contrast, 5 (8%) of 60 patients in the mini-laparotomy group experienced distal shunt failure (p = 0.029). Intraoperative complications occurred in 2 patients (both in the laparoscopic group), and abdominal pain led to catheter removal in 1 patient per group. Infections occurred in 1 patient in the laparoscopic group and 3 in the mini-laparotomy group. The mean durations of surgery and hospitalization were similar in the 2 groups. CONCLUSIONS While overall shunt failure rates were similar in the 2 groups, the use of laparoscopic shunt placement significantly reduced the rate of distal shunt failure compared with mini-laparotomy.

Concepts: Hospital, Randomized controlled trial, Surgery, Physician, Hydrocephalus, Laparoscopic surgery, Laparoscopy, Cerebral shunt

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OBJECTIVE The aim of this study was to provide a comprehensive benchmark of 30-day ventriculoperitoneal (VP) shunt failure rates for a single institution over a 5-year study period for both adult and pediatric patients, to compare this with the results in previously published literature, and to establish factors associated with shunt failure. METHODS A retrospective database search was undertaken to identify all VP shunt operations performed in a single, regional neurosurgical unit during a 5-year period. Data were collected regarding patient age, sex, origin of hydrocephalus, and whether the shunt was a primary or secondary shunt. Operative notes were used to ascertain the type of valve inserted, which components of the shunt were adjusted/replaced (in revision cases), level of seniority of the most senior surgeon who participated in the operation, and number of surgeons involved in the operation. Where appropriate and where available, postoperative imaging was assessed for grade of shunt placement, using a recognized grading system. Univariate and multivariate models were used to establish factors associated with early (30-day) shunt failure. RESULTS Six hundred eighty-three VP shunt operations were performed, of which 321 were pediatric and 362 were adult. The median duration of postoperative follow-up for nonfailed shunts (excluding deaths) was 1263 days (range 525-2226 days). The pediatric 30-day shunt failure rates in the authors' institution were 8.8% for primary shunts and 23.4% for revisions. In adults, the 30-day shunt failure rates are 17.7% for primary shunts and 25.6% for revisions. In pediatric procedures, the number of surgeons involved in the operating theater was significantly associated with shunt failure rate. In adults, the origin of hydrocephalus was a statistically significant variable. Primary shunts lasted longer than revision shunts, irrespective of patient age. CONCLUSIONS A benchmark of 30-day failures is presented and is consistent with current national databases and previously published data by other groups. The number of surgeons involved in shunt operations and the origin of the patient’s hydrocephalus should be described in future studies and should be controlled for in any prospective work. The choice of shunt valve was not a significant predictor of shunt failure. Most previous studies on shunts have concentrated on primary shunts, but the high rate of early shunt failure in revision cases (in both adults and children) is perhaps where future research efforts should be concentrated.

Concepts: Patient, Surgery, Physician, Failure, Hydrocephalus, Failure rate, Annualized failure rate, Cerebral shunt

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OBJECT The rate of CSF shunt failure remains unacceptably high. The Hydrocephalus Clinical Research Network (HCRN) conducted a comprehensive prospective observational study of hydrocephalus management, the aim of which was to isolate specific risk factors for shunt failure. METHODS The study followed all first-time shunt insertions in children younger than 19 years at 6 HCRN centers. The HCRN Investigator Committee selected, a priori, 21 variables to be examined, including clinical, radiographic, and shunt design variables. Shunt failure was defined as shunt revision, subsequent endoscopic third ventriculostomy, or shunt infection. Important a priori-defined risk factors as well as those significant in univariate analyses were then tested for independence using multivariate Cox proportional hazard modeling. RESULTS A total of 1036 children underwent initial CSF shunt placement between April 2008 and December 2011. Of these, 344 patients experienced shunt failure, including 265 malfunctions and 79 infections. The mean and median length of follow-up for the entire cohort was 400 days and 264 days, respectively. The Cox model found that age younger than 6 months at first shunt placement (HR 1.6 [95% CI 1.1-2.1]), a cardiac comorbidity (HR 1.4 [95% CI 1.0-2.1]), and endoscopic placement (HR 1.9 [95% CI 1.2-2.9]) were independently associated with reduced shunt survival. The following had no independent associations with shunt survival: etiology, payer, center, valve design, valve programmability, the use of ultrasound or stereotactic guidance, and surgeon experience and volume. CONCLUSIONS This is the largest prospective study reported on children with CSF shunts for hydrocephalus. It confirms that a young age and the use of the endoscope are risk factors for first shunt failure and that valve type has no impact. A new risk factor-an existing cardiac comorbidity-was also associated with shunt failure.

Concepts: Clinical trial, Observational study, Hydrocephalus, Valves, Cerebral shunt

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A 61-year-old male patient presented with recurrent malignant meningioma involving the left optic canal and decreased vision from the left eye. The patient had undergone orbital exenteration on the right 2 years ago. The decision to treat the patient was made based on the significant vision deterioration and rapid tumor growth. Endoscopic transsphenoidal approach considered the most suitable route due to the inferomedial invasion of the optic canal. Gross total removal was achieved and the patient’s vision improved postoperatively. The patient developed hydrocephalus 4 weeks postoperatively and cerebrospinal fluid (CSF) leak. Ventriculoperitoneal shunt placement corrected both hydrocephalus and CSF leak. The link to the video can be found at: https://youtu.be/2cOF0pf5gAk .

Concepts: Left-wing politics, Cerebrospinal fluid, Centre-right, Right-wing politics, Hydrocephalus, Political spectrum, French Revolution, Cerebral shunt

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An 82-year-old woman underwent a ventriculoperitoneal (VP) shunt placement to treat hydrocephalus secondary to a right thalamic intracerebral hemorrhage. Pneumothorax and subcutaneous emphysema was noted 2 hours later. No respiratory distress was noted. A chest computed tomography scan revealed that the shunt tube had penetrated the diaphragm and entered the pleural space. The shunt tube penetrated the lung parenchyma and exited the pleural space via the third intercostal space. She underwent chest drainage and VP shunt reposition. The VP shunt functioned properly and no infection was noted. Bending the shunt passer slightly and keeping the passer tip pointed upward and palpable during its advancement may prevent this complication. It may be acceptable to leave the shunt tube in place after chest drainage for pneumothorax.

Concepts: Pulmonology, Lung, Respiratory system, Pneumothorax, Hydrocephalus, Pleural cavity, Tension pneumothorax, Cerebral shunt