Different origins of hydrocephalus lead to different shunt revision rates

doi:10.1016/j.pjnns.2016.11.007

Neurologia i Neurochirurgia Polska

Volume 51, Issue 1, January–February 2017, Pages 72-76

https://doi.org/10.1016/j.pjnns.2016.11.007 Get rights and content

Abstract

Introduction

Hydrocephalus (HC) occurs due to multiple origins. Time course and dynamic of HC and its therapies differ between underlying pathologies. Different revision rates due to the type of HC are expected. Though hydrocephalus is known to be a life time condition, the lack of shunt malfunction years or decades after initial shunt insertion raises the hope of a superfluous shunt.

Methods

We conducted a retrospective survey of our OR-database during a 10 year period. All newly inserted shunt systems and subsequent shunt revisions are recorded according to quantity and time point. All patients were subdivided according their aetiology of HC.

Results

260 patients were eligible with a follow-up of 4.5 years. Subgroups were: 90 patients with NPH, 76 patients with posthaemorrhagic and 16 patients had posttraumatic HC. 22 received a shunt as a consequence of a tumour, 41 were children and 15 for other causes. Overall revision rate was 39.5%. During the first 6 months 55.6%, 57.9% and 75% of patients with NPH, posthaemorrhagic and posttraumatic HC had revisions. In contrast only 38.1% of children and 20% of tumour cases required early revision.

Conclusion

Two different patterns of revision are evident: mainly early revisions in morphologically stable diseases such as posthaemorrhagic, posttraumatic and NPH and predominantly late revisions in changing organisms such as children and tumour patients. The conception HC may be transient because of a lack of late revisions cannot be supported by this data.

Introduction

Hydrocephalus (HC) is a frequent entity in daily neurosurgical practice. In addition to endoscopic third ventriculostomie (ETV) CSF shunting is still the most common therapy for HC of different aetiologies. Shunt failure presents a significant medical burden. Studies have shown an overall shunt failure rate up to 45% within the first year [1], [2], [3].

Because of this major problem, the concept HC could be transient because of a lack of late revisions is tempting and advocated by O’Kelly et al. especially in the case of posthaemorrhagic HC [4].

This study was undertaken to compare different hydrocephalus types with the revision rates and their time course to give a hint to the question if HC could be a temporary condition especially in the case of posthaemorrhagic HC.

Section snippets

Study design

This study was approved by the local ethic committee. We conducted a retrospective cohort study of all CSF shunts that were placed in a 10-year period between 1st January 2004 and 31st December 2013. Only patients who had their initial shunt insertion within the 10-year study period were included. Follow-up was extended up to August 2014. For each patient the following was recorded: age at initial shunt insertion, date of initial shunt insertion and all subsequent revisions with date of

Results

333 patients received a newly inserted shunt system within the 10 year period. 56 patients died in the first year after shunt insertion. 17 patients were lost to follow-up. According to the inclusion criteria 260 had at least one year follow-up and were eligible for this study with a mean follow-up period of 1656 days = 4.5 years (range 366–4369 days).

122 patients were men, 134 women. 75.7% had ventriculo-peritoneal shunts. 23.5% had ventriculo-atrial shunts. Two patients (0.8%) received a

Discussion

Shunt dependency is supposed to be a lifelong condition. But due to an unacceptable high rate of true or suspected shunt failure the concept that HC could be transient in special cases is tempting to embrace. The often observed fact that shunts are functioning well for decades after numerous revisions in the early time course raise the question if this shunt is still necessary in the later course. Particularly in posthaemorrhagic HC the discussion is raised perpetually in the literature [4].

Conclusion

Different aetiology of HC leads to significantly different revision rates even after correction for follow-up. Age is another strong predictor for revisions. The older a patient, the less likely shunt revisions are performed.

There are two different patterns of shunt revisions: mainly early revisions were performed in a morphologically stable disease such as posthaemorrhagic, posttraumatic and NPH. On the other hand a high proportion of late shunt revisions embodies a morphologically dynamic

Conflict of interest

None declared.

Acknowledgement and financial support

None declared.

Ethics

The work described in this article has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans; Uniform Requirements for manuscripts submitted to Biomedical journals.

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This may be explained by the differences in number of patients in each of our categories. Nevertheless, the low proportion of failures in those shunted for NPH is comparable to those found in previous studies [25, 26]. Overdrainage and underdrainage reflected only 6.1% of failures, respectively (2 of 33).
There is extensive debate on the role of fixed pressure shunts in the adult population. Most studies assessing fixed pressure valves do not consider the potential for changes in technique and management of shunts. We sought to examine the natural history of fixed pressure.
We conducted a retrospective chart review of 169 patients undergoing shunt placement by the senior author Daniel Wecht (DW). The etiology of shunt placement, shunt failure rates, and outcome data was assessed for each patient.
Overall, 126 patients underwent initial shunt placement. Thirty-three (26.2%) patients required at least one shunt revision during follow-up. The most common cause of first time revision was mechanical shunt malfunction (13, 39.4%), followed by infection (7, 21.2%), and shunt migration (6, 18.2%). Three patients (9.1%) required revision due to misplaced catheters. Underdrainage or overdrainage of shunts each resulted in revisions for 2 (6.1%) patients. The mean follow-up length was 28.1 ± 6.1 months.
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Our finding of a tendency for fewer shunt infections in teaching cases is likely explained by the overall low incidence of infections in our cohort and might represent a type 1 error. Different shunt revision rates were reported in a recently published 10-year single-center series of 260 patients from Germany.13 The highest revision rates were found in posttraumatic hydrocephalus (26.7%) and the lowest rates in NPH (5.6%),13 which is in agreement with a larger single-center study by Reddy et al.12 Revision and complication rates are also known to be higher in the pediatric population12,13 and therefore do not allow direct comparison of our data from the adult population.
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A retrospective 2-center study was performed comparing consecutive patients undergoing shunt implantation by a supervised neurosurgery resident (teaching cases) versus a board-certified faculty neurosurgeon (nonteaching cases). The primary end point was surgical revision after shunting. Univariate and multivariate Cox proportional hazard models (Breslow method for ties) with time censored at 2 years were used to examine time-to-event data. Operation time, length of hospitalization, intracranial hemorrhage, and misplacement of the shunt catheter were other outcome measures to be compared between the groups.
A total of 320 shunts (180 [56.3%] teaching and 140 [43.7%] nonteaching cases) with a mean follow-up of 563 ± 771 days (standard deviation) were analyzed. Revision rates for the entire cohort were 9.3% at 90 days, 13.3% at 6 months, 18.4% at 1 year, and 26.5% at 2 years. In univariate analysis, teaching cases were 96% as likely as nonteaching cases to be surgically revised (hazard ratio, 0.96; 95% confidence interval, 0.54–1.70; P = 0.877). In multivariate analysis adjusted for indication and shunt type, teaching cases were 94% as likely as nonteaching cases to undergo surgical revision (hazard ratio, 0.94; 95% confidence interval, 0.53–1.69; P = 0.847). There were no group differences in operation time, length of hospitalization, intracranial hemorrhage, and rates of shunt misplacement.
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Retroperitoneal Migration and Transgluteal Extrusion of a Distal Lumboperitoneal Shunt Catheter: An Unusual Complication of Cerebrospinal Fluid Shunt
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Original research articleDifferent origins of hydrocephalus lead to different shunt revision rates

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Section snippets

Study design

Results

Discussion

Conclusion

Conflict of interest

Acknowledgement and financial support

Ethics

A comparison between ventriculo-peritoneal and ventriculo-atrial CSF shunts in relation to rate of revision and durability

Acta Neurochir

Randomised trial of cerebrospinal fluid shunt valve design in paediatric hydrocephalus

Neurosurgery

Hydrocephalus Clinical Research Network: risk factors for shunt malfunction in pediatric hydrocephalus: a multicenter prospective cohort study

J Neurosurg Pediatr

Shunt-dependant hydrocephalus after aneurysmal subarachnoid haemorrhage: incidence, predictors, and revision rates

J Neurosurg

A multi-institutionnal, 5-year analysis of initial and multiple ventricular shunt revisions in children

Neurosurgery

Frequency and causes of shunt revisions in different CSF shunt types

Acta Neurochir

Ventricular shunting for hydrocephalus in children: patients, procedures, surgeons, and institutions in English Canada, 1989–2001

Eur J Pediatr Surg Suppl

Perioperative risk factors for short term shunt revisions in adult hydrocephalus patients

J Neurol Neurosurg Psychiatr

Shunt failures and complications in adults as related to shunt type, diagnosis, and the experience of the surgeon

Neurosurgery

Ventriculoperitoneal shunt complications in Carlifornia: 1990 to 2000

Neurosurgery

Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome

Neurosurgery

Five years experience with gravitational shunts in chronic hydrocephalus of adults

Acta Neurochir

Diagnosis, treatment, and analysis of long-term outcomes in idiopathic normal pressure hydrocephalus

Neurosurgery

Idiopathic normal pressure hydrocephalus: results of a prospective cohort of 236 shunted patients

Acta Neurochir Suppl

NPH: long-term outcome after shunt surgery

J Neurol Neurosurg Psychiatr

Original research article
Different origins of hydrocephalus lead to different shunt revision rates