Cerebrospinal Fluid Shunting Complications in Children

Abstract

Although cerebrospinal fluid (CSF) shunt placement is the most common procedure performed by pediatric neurosurgeons, shunts remain among the most failure-prone life-sustaining medical devices implanted in modern medical practice. This article provides an overview of the mechanisms of CSF shunt failure for the 3 most commonly employed definitive CSF shunts in the practice of pediatric neurosurgery: ventriculoperitoneal, ventriculopleural, and ventriculoatrial. The text has been partitioned into the broad modes of shunt failure: obstruction, infection, mechanical shunt failure, overdrainage, and distal catheter site-specific failures. Clinical management strategies for the various modes of shunt failure are discussed as are research efforts directed towards reducing shunt complication rates. As it is unlikely that CSF shunting will become an obsolete procedure in the foreseeable future, it is incumbent on the pediatric neurosurgery community to maintain focused efforts to improve our understanding of and management strategies for shunt failure and shunt-related morbidity.

Reduced cell attachment to poly(2‐hydroxyethyl methacrylate)‐coated ventricular catheters in vitro

“…[3][4][5][6][7] Over half of these failures are caused by obstruction of the ventricular catheter (portion entering the cerebral ventricles) with cells and tissue. 7,8 Specifically, studies using animal models [9][10][11][12] as well as analysis of catheters explanted from human patients 8,[13][14][15][16] have revealed that the resident innate immune cells of the central nervous system, astrocytes and microglia, appear to serve as the pathophysiologic lynchpin in the process of ventricular catheter obstruction by directly attaching to implanted catheter surfaces in large numbers, serving as an interface for the secondary binding of less reactive tissue types including choroid plexus to the catheter surface, and, presumably, through the recruitment of additional inflammatory cells to the site of an implanted foreign body via cytokine signaling.…”

Epidural Fibrin Sealant Injection for the Management of Cerebrospinal Fluid Leak Following Dural Puncture in Children

“…Fibrin sealant is a common neurosurgical adjunct administered to enhance watertight dural closure with its high tensile strength and toleration of moist environments. The fibrin plug theory hypothesizes that adhesion created at the dural tear promotes healing by promoting the immediate stimulation of fibroblasts; direct tamponade likely provides additional effect [19]. Fibrin sealants have demonstrated success in treatment of CSF leaks following open surgery [10,19,20].…”

Shunt Revision to Ventriculoatrial Shunt Due to Long-Term Abdominal Distension Complicated by Neonatal Necrotizing Enterocolitis and Cerebrospinal Fluid Overproduction after Ventriculoperitoneal Shunt for the Management of Post-Hemorrhagic Hydrocephalus: A Case Report

“…Treatment methods for hydrocephalus aside from VP shunting include VA shunting, third ventriculostomy, choroid plexotomy, and choroidal artery embolization 6,13) . Although CSF shunt placement is the most com-mon procedure performed by pediatric neurosurgeons, shunts remain among the most failure-prone implantation devices in modern medical practice, with failure rates of 30% to 40% at 1 year and approximately 50% at 2 years in pediatric patients 3) . The most classical method of treatment for patients with hydrocephalus is the placement of a VP shunt where a distal catheter is placed into the peritoneal space, and it is important to recognize that intra-abdominal pressure can be one of the major determinants of effective shunt function.…”

“…In these cases, VA shunts should be considered rather than VP shunts 6,8) . Despite this, when CSF absorption is absolutely or relatively decreased in the abdominal cavity, the current opinion is that VA shunts should be recommended only after experiencing repeated VP shunt failures since VA shunts may yield serious complications 3,4,10) . However, it is the opinion of the authors of this investigation that in patients who demonstrate both CSF overproduction and a decrease in CSF absorption, a VA shunt should be strongly considered over a VP shunt.…”