Monte Carlo simulation of cerebrospinal fluid shunt failure and definition of instability among shunt-treated patients with hydrocephalus

Piatt, Joseph H.; Cosgriff, Marg

doi:10.3171/ped-07/12/474

Cited by 10 publications

(11 citation statements)

References 7 publications

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“…The "flattening" of the ETV survival curve around 6 months contrasts with the pattern for shunt failure, which is one of continued failure over time. 1,3,15,16 Although ETV failure does occur beyond 6 months, it appears to be uncommon. 2 Thus, for a population of infants with parameters known to predict a chance of ETV failure that equals or even exceeds that for shunt failure, ETV may still be supported as the best initial treatment since virtually all failures will occur within this "safe window.…”

Section: Discussionmentioning

confidence: 99%

“…The probability of shunt malfunction in the first year after placement and subsequently over time is universally recognized. 15,16 If, however, the likelihood of failure for primary treatment with ETV in a particular child were known to exceed that expected for shunting, then a shunt may be the optimal choice.Based on our large patient population in Uganda, we initially showed that an age younger than 1 year at time of treatment and the absence of visible evidence of flow across the ETV stoma at the time of surgery each significantly correlated with ETV failure. 20 It was later shown that adding bilateral lateral ventricle CPC to the procedure increased the likelihood of success in those younger Object.…”

mentioning

confidence: 99%

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confidence: 99%

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Intraoperative assessment of cerebral aqueduct patency and cisternal scarring: impact on success of endoscopic third ventriculostomy in 403 African children

Warf

Kulkarni

2010

PED

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Object In the setting of a developing country where preoperative imaging may be limited, the authors wished to determine whether cisternal scarring or aqueduct patency at the time of surgery was sufficiently predictive of the failure of endoscopic third ventriculostomy (ETV) to justify shunt placement at the time of the initial operation. Methods The status of the prepontine cistern and aqueduct at the time of ventriculoscopy was prospectively recorded in 403 children in whom an ETV had been completed. Kaplan-Meier methods were used to construct survival curves. A Cox proportional hazards model was used to provide estimates of HRs for the time to ETV failure. Several independent variables were tested in a single multivariable model, including those previously shown to be associated with ETV survival, that is, age, hydrocephalus etiology, and extent of choroid plexus cauterization (CPC). In addition, intraoperative variables of particular interest were included in the analysis: status of the aqueduct at surgery (closed vs open) and status of the prepontine cistern at surgery (scarred vs clean/unscarred). Multicollinearity was not a concern since the variance inflation factors for all variables were < 2. The examination of stratified survival curves confirmed the appropriateness of the proportional hazards assumption for each variable. Results Overall actuarial 3-year success was 57%. Consistent with previous results, age, hydrocephalus etiology, and extent of CPC were significantly associated with ETV success. A closed aqueduct and an unscarred cistern were each independently associated with significantly better ETV success (HRs of 0.66 and 0.44, respectively). The presence of cisternal scarring more than doubled the risk of ETV failure, and an open aqueduct increased the risk of failure by 50%. Conclusions Intraoperative observations of the aqueduct and prepontine cistern are independent predictors of the risk of ETV failure and can be used to further refine outcome predictions based on age, hydrocephalus etiology, and extent of CPC. Further studies will test validity in several African centers and determine what threshold of failure risk should prompt shunt placement at the initial operation.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Intraoperative assessment of cerebral aqueduct patency and cisternal scarring: impact on success of endoscopic third ventriculostomy in 403 African children

Warf

Kulkarni

2010

PED

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“…15 Briefly, actuarial shunt survival data were developed in life-table format from a previously published institutional case series with exponential extrapolation to reach 216 months.…”

Section: Methodsmentioning

confidence: 99%

“…Piatt and Cosgriff 15 performed a digital simulation of the 10-year experiences of individuals with newly diagnosed hydrocephalus by using published shunt survival data. This exercise produced estimates of expected numbers of hospitalizations over the simulated study period with 95% and 99% confidence intervals.…”

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confidence: 99%

Quality measures for the management of hydrocephalus: concepts, simulations, and preliminary field-testing

Barton

Campbell

Piatt

2013

PED

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Object The authors define and examine the properties of 2 new, practice-based quality measures for the management of hydrocephalus. Methods The Surgical Activity Rate (SAR) is defined as the number of definitive operations for the treatment of hydrocephalus performed in a neurosurgical practice over the course of a year, divided by the number of patients with hydrocephalus seen in follow-up during that year. The Revision Quotient (RQ) is defined as the number of definitive revision operations performed in a neurosurgical practice in the course of a year, divided by the number of definitive initial operations during that year for patients with newly diagnosed hydrocephalus. Using published actuarial shunt survival data, the authors conducted Monte Carlo simulations of a pediatric neurosurgical practice to illustrate the properties and interpretations of the SAR and RQ. They used data from the Kids' Inpatient Database (KID) for 2009 to calculate RQs for hospitals accounting for more than 10 admissions coded for initial CSF shunt insertions. Results During the initial growth phase of a simulated neurosurgical practice, the SAR approached its steady-state value much earlier than the RQ. Both measures were sensitive to doubling or halving of monthly failure rates. In the 2009 KID, 117 hospitals reported more than 10 initial shunt insertions. The weighted mean (± standard deviation) RQ for these hospitals was 1.79 ± 0.69. Among hospitals performing 50 or more initial shunt insertions, the RQ ranged between 0.71 and 3.65. Conclusions The SAR and RQ have attractive qualitative features as practice-based quality measures. The RQ, at least, exhibits clinically meaningful interhospital variation as applied to CSF shunt surgery. The SAR and RQ merit prospective field-testing as measures of quality in the management of childhood hydrocephalus.

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Dual catheter and double-lumen cerebrospinal fluid shunt systems with backflow mechanisms

Patel

Boyle

et al. 2023

Childs Nerv Syst

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Monte Carlo simulation of cerebrospinal fluid shunt failure and definition of instability among shunt-treated patients with hydrocephalus

Cited by 10 publications

References 7 publications

Intraoperative assessment of cerebral aqueduct patency and cisternal scarring: impact on success of endoscopic third ventriculostomy in 403 African children

Intraoperative assessment of cerebral aqueduct patency and cisternal scarring: impact on success of endoscopic third ventriculostomy in 403 African children

Quality measures for the management of hydrocephalus: concepts, simulations, and preliminary field-testing

Dual catheter and double-lumen cerebrospinal fluid shunt systems with backflow mechanisms

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