Anterior versus posterior entry site for ventriculoperitoneal shunt insertion: a randomized controlled trial by the Hydrocephalus Clinical Research Network

Abstract

OBJECTIVE The primary objective of this trial was to determine if shunt entry site affects the risk of shunt failure. METHODS The authors performed a parallel-design randomized controlled trial with an equal allocation of patients who received shunt placement via the anterior entry site and patients who received shunt placement via the posterior entry site. All patients were children with symptoms or signs of hydrocephalus and ventriculomegaly. Patients were ineligible if they had a prior history of shunt insertion. Patients received a ventriculoperitoneal shunt after randomization; randomization was stratified by surgeon. The primary outcome was shunt failure. The planned minimum follow-up was 18 months. The trial was designed to achieve high power to detect a 10% or greater absolute difference in the shunt failure rate at 1 year. An independent, blinded adjudication committee determined eligibility and the primary outcome. The study was conducted by the Hydrocephalus Clinical Research Network. RESULTS The study randomized 467 pediatric patients at 14 tertiary care pediatric hospitals in North America from April 2015 to January 2019. The adjudication committee, blinded to intervention, excluded 7 patients in each group for not meeting the study inclusion criteria. For the primary analysis, there were 229 patients in the posterior group and 224 patients in the anterior group. The median patient age was 1.3 months, and the most common etiologies of hydrocephalus were postintraventricular hemorrhage secondary to prematurity (32.7%), myelomeningocele (16.8%), and aqueductal stenosis (10.8%). There was no significant difference in the time to shunt failure between the entry sites (log-rank test, stratified by age < 6 months and ≥ 6 months; p = 0.061). The hazard ratio (HR) of a posterior shunt relative to an anterior shunt was calculated using a univariable Cox regression model and was nonsignificant (HR 1.35, 95% CI, 0.98–1.85; p = 0.062). No significant difference was found between entry sites for the surgery duration, number of ventricular catheter passes, ventricular catheter location, and hospital length of stay. There were no significant differences between entry sites for intraoperative complications, postoperative CSF leaks, pseudomeningoceles, shunt infections, skull fractures, postoperative seizures, new-onset epilepsy, or intracranial hemorrhages. CONCLUSIONS This randomized controlled trial comparing the anterior and posterior shunt entry sites has demonstrated no significant difference in the time to shunt failure. Anterior and posterior entry site surgeries were found to have similar outcomes and similar complication rates.

Predictors of the degree of ventricular catheter obstruction: duration of implantation, number of prior revision surgeries, contact with the ventricular wall and the surgical approach

“…The parietal approach was associated with fewer empty holes (N, p = 0.009), frontal & occipital approaches were associated with fewer holes with a scattering of cells ('S', p = 0.023 and 0.029, respectively), and lastly, occipital approach was associated with greater number of holes with protruding tissue aggregates (M, p = 0.041). These results suggest that the entry site of the catheter is a predictor of the degree of shunt obstruction which appears to contradict the overarching outcome of the recent randomized controlled trial through the Hydrocephalus Clinical Research Network 30 . However, this work grouped all types of failure together and did not specify how many of the failed shunts from each approach had failed speci cally due to obstructions.…”

Analysis of the risk factors of post-operative seizure in pediatric patients with hydrocephalus undergoing endoscopic third ventriculostomy

“…In a child with no seizure after ETV, ventriculoperitoneal shunting was performed 3 weeks after the rst surgery, and epilepsy occurred at 4 years of follow-up, which might be associated with shunt surgery, and a meta-analysis reported that the risk of acquiring seizures/epilepsy in shunted non-infectious hydrocephalus children was 15.75 times higher than that in normal children [18]. A randomized controlled trial compared the anterior and posterior shunt entry sites, and found no signi cant difference in the incidence rate of new-onset epilepsy [19], which could be related to cortical injury and long-term stimulation of the shunt as a foreign body, indicating that cortical disruption or irritation from the shunt catheter itself may contribute to post-shunt seizure development. The child has been well controlled by antiepileptic treatment.…”

Ventricular Peritoneal Shunting Using Modified Keen’s Point Approach: Technical Report and Cases Series

“…There are limited analyses comparing complications and revision rates in relation to the different surgical ventricular access options [10,16,[28][29][30] showing no significant differences.…”

“…By analyzing the occurrence of ventricular catheter displacement, we report an overall rate of 4.2% with an even better 2.2% rate considering the cases after the first 50 (initial learning curve). The malpositioning rates reported in the literature vary from 4.5% to 32.5% [11,16,30,31]. We theorize some potential advantages of the temporal access: firstly, the catheter placement does not require the patient's head to be rotated during procedure, as for frontal access, leaving the landmarks fixed and reproducible; secondly, the lateral ventricle can be found as close as 3-4 cm from the cortical surface and a simpler access to the wide area of the ventricular trigone is possible, reducing potential parallax errors and allowing blunt catheter positioning.…”