Shunt-dependent hydrocephalus: management style among members of the American Society of Pediatric Neurosurgeons

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>The authors conducted a survey to evaluate differences in the understanding and management of shunt-dependent hydrocephalus among members of the American Society of Pediatric Neurosurgeons (ASPN).</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>Surveys were sent to all 204 active ASPN members in September 2014. One hundred thirty responses were received, representing a 64% response rate. Respondents were asked 13 multiple-choice and free-response questions regarding 4 fundamental problems encountered in shunted-hydrocephalus management: shunt malfunction, chronic cerebrospinal fluid (CSF) overdrainage, chronic headaches, and slit ventricle syndrome (SVS).</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Respondents agreed that shunt malfunction occurs most often as the result of ventricular catheter obstruction. Despite contrary evidence in the literature, most respondents (66%) also believed that choroid plexus is the tissue most often found in obstructed proximal catheters. However, free-text responses revealed that the respondents’ understanding of the underlying pathophysiology of shunt obstruction was highly variable and included growth, migration, or adherence of choroid plexus, CSF debris, catheter position, inflammatory processes, and CSF overdrainage. Most respondents considered chronic CSF overdrainage to be a rare complication of shunting in their practice and reported wide variation in treatment protocols. Moreover, despite a lack of evidence in the literature, most respondents attributed chronic headaches in shunt patients to medical reasons (for example, migraines, tension). Accordingly, most respondents managed headaches with reassurance and/or referral to pain clinics. Lastly, there were variable opinions on the etiology of slit ventricle syndrome (SVS), which included early shunting, chronic overdrainage, and/or loss of brain compliance. Beyond shunt revision, respondents reported divergent SVS treatment preferences.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>The survey shows that there is wide variability in the understanding and management of shunt-dependent hydrocephalus and its complications. Such discrepancies appear to be derived partly from inconsistent familiarity with existing literature but especially from a paucity of high-quality publications.</jats:p></jats:sec>

Current epidemiology of cerebrospinal fluid shunt surgery in the UK and Ireland (2004–2013)

“…Therefore, considering all of the above factors, the observed variations likely represent some actual epidemiological differences for each underlying diagnosis,19 differing clinical practice in decision to shunt, and alternative treatment options,3 20 in line with previous reports 21…”

Overdrainage-related ependymal bands: a postulated cause of proximal shunt obstruction

“…All but 1 patient had at least 1 shunt revision surgery prior to the observation of ependymal bands. Valve types were reflective of national practice patterns, 21 and include programmable valves (20%), simple differential pressure valves (52%), differential pressure valves with integrated antisiphon device (12%), flow-regulated valves (8%), and unknown (7%). Although the results do not demonstrate an obvious association between ependymal bands and valve type, patient age, or hydrocephalus etiology, the small sample size in each group precludes detailed statistical analyses.…”

“…Choroid plexus and blood vessels may migrate into catheter orifices presumably through a similar overdrainage mechanism. Despite growing evidence to the contrary, 4,36,37 surgeons often attribute obstructive shunt failure to choroid plexus migration into the catheter, 21 an attribution that appears to have been popularized by several early histological studies. 7,11 The present study further refutes the notion that the choroid plexus is responsible for most ventricular obstructions.…”

“…These discrepancies appear to arise from a lack of highquality evidence and inconsistent knowledge of existing literature. 21 Interestingly, common to all these theories is the yet ill-defined observation that tissue, cellular debris, or reactive processes lodge in the ventricular catheter.…”

North American survey on the post-neuroimaging management of children with mild head injuries

“…Survey studies offer an efficient means of describing current practice, identifying knowledge gaps, and highlighting areas requiring further investigation. 7,31 With these motivations, we conducted a survey to characterize current practice patterns and identify influences on physician decision making in the post-neuroimaging acute care of children with mTBI complicated by ICI.…”