Congenital hydrocephalus and ventriculoperitoneal shunts: influence of etiology and programmable shunts on revisions

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Hydrocephalus is a notorious neurosurgical disease that carries the adage “once a shunt always a shunt.” This study was conducted to review the treatment results of pediatric hydrocephalus.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>Pediatric patients who underwent ventriculoperitoneal shunt surgery over the past 14 years were reviewed for shunt revisions. Variables studied included age at shunt placement, revision, or replacement; programmable shunts; infection; obstruction; and diagnosis (congenital, posthemorrhagic, craniospinal dysraphism, and others including trauma, tumors, and infection). Multiple regression analysis methods were used to determine independent risk factors for shunt failure and the number of shunt revisions. The Kaplan-Meier method of survival analysis was used to compare etiologies on the 5-year survival (revision-free) rate and the median 5-year survival time.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>A total of 253 patients were studied with an almost equal sex distribution. There were 92 patients with congenital hydrocephalus, 69 with posthemorrhagic hydrocephalus, 48 with craniospinal dysraphism, and 44 with other causes. Programmable shunts were used in 73 patients (other types of shunts were used in 180 patients). A total of 197 patients (78%) underwent revision surgeries due to shunt failures. The mortality rate was 1.6%. Age at first revision, the 5-year survival rate, and the median 5-year survival time were significantly less for both posthemorrhagic and craniospinal dysraphism than for either the congenital or “other” group (p &lt; 0.05). The failure rate and number of revisions were not significantly reduced with programmable shunts compared with either pressure-controlled or no-valve shunts (p &gt; 0.5).</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Posthemorrhagic hydrocephalus and craniospinal dysraphism hydrocephalus had significantly earlier revisions than congenital and other etiologies. Programmable systems did not reduce the failure rate or the average number of shunts revisions.</jats:p></jats:sec>

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 5: Effect of valve type on cerebrospinal fluid shunt efficacy

“…The investigators did not find a significant difference in shunt survival between the 3 valve types in either the short-term (Drake 1998 5 ) or extended 19 follow-up. Eleven Class II studies 4,11,15,21,23,24,27,33,36,41,44 in which differing valve types were compared also failed to demonstrate a superior valve when shunt survival was assessed. Jain et al 15 (2000) conducted a prospective cohort study in which they compared shunts using a standard differential pressure valve with a Delta (Medtronic) flowregulating valve.…”

“…27 The authors found that programmable valve placement was associated with a reduced risk of both overall shunt revision (35% vs 54% in the nonprogrammable group; p = 0.016) and proximal shunt obstruction (12% vs 28% in the nonprogrammable group; p = 0.006). Notarianni et al 33 (2009) found no significant difference in a retrospective review of 253 patients who underwent shunt placement with either a programmable (Strata or Codman Hakim) or nonprogrammable (pressure-controlled or not specified) valve. The failure rate among the programmable valve group was 76.1%, and that among the differential pressure valve group was 80.0% (p = 0.11).…”

“…Five Class II studies 11,24,27,33,36 evaluated programmable valves. Pollack et al 36 (1999) conducted a multicenter randomized controlled trial in which they compared the programmable Codman Hakim valve to the surgeon's choice of any conventional valve.…”

Surgically Correctable Fetal Anomalies: Ultrasound Diagnosis and Management

“…33 Posthemorrhagic hydrocephalus and hydrocephalus connected with craniospinal dysraphism had significantly earlier revisions than congenital and other etiologies. 34 …”

Nonprogrammable and programmable cerebrospinal fluid shunt valves: a 5-year study

“…However, investigators have not agreed on a clearly superior valve when used in a broad range of children with hydrocephalus. 1,[7][8][9]12,13,16,[20][21][22]29,32 Conventional NPVs require surgeons to select an optimal opening pressure before implantation. Inaccurate estimates of the shunt valve function in situ may necessitate replacement of the valve to prevent over-or underdrainage.…”