Ventriculoperitoneal shunt surgery and the incidence of shunt revision in adult patients with hemorrhage-related hydrocephalus

doi:10.1016/j.clineuro.2012.02.050

Clinical Neurology and Neurosurgery

Volume 114, Issue 9, November 2012, Pages 1211-1216

https://doi.org/10.1016/j.clineuro.2012.02.050 Get rights and content

Abstract

Objective

Ventriculoperitoneal shunt surgery remains the most widely accepted neurosurgical procedure for the management of hydrocephalus. However, shunt failure and complications are common and may require multiple surgical procedures during a patient's lifetime. The purpose of this study is to evaluate the ventriculoperitoneal shunt surgery and the incidence of shunt revision in adult patients with hemorrhage-related hydrocephalus.

Methods

Adult patients who underwent ventriculoperitoneal shunt placement for hemorrhage-related hydrocephalus from October 1990 to October 2009 were included in this study. Medical charts, operative reports, imaging studies, and clinical follow-up evaluations were reviewed and analyzed retrospectively.

Results

A total of 133 adult patients with the median age of 54.5 years were included. Among patients, 41% were males, and 62% Caucasians. The overall shunt revision rate was 51.9%. The shunt revision rate within the first 6 months after the initial placement of ventriculoperitoneal shunts was 45.1%. The median time to first shunt revision was 0.50 (95% CI, 0.24–9.2) months. No significant association was observed between perioperative variables (gender, ethnicity, hydrocephalus type, or hemorrhage type) and the shunt revision rate in these patients. Major causes of shunt revision include infection (3.6%), overdrainage (7.6%), obstruction (4.8%), proximal shunt complication (7.6%), distal shunt complication (3.6%), old shunt dysfunction (6.8%), valve malfunction (10.0%), externalization (3.6%), shunt complication (12.0%), shunt adjustment/replacement (24.0%) and other (16.4%).

Conclusion

Although ventriculoperitoneal shunting remains to be the treatment of choice for adult patients with post hemorrhage-related hydrocephalus, a thorough understanding of predisposing factors related to the shunt failure is necessary to improve treatment outcomes.

Introduction

Hydrocephalus is known common sequelae in patients with post-hemorrhagic conditions, including subarachnoid hemorrhage (SAH), or subdural hemorrhage (SDH), intracranial hemorrhage (ICH) and intraventricular hemorrhage (IVH) [1], [2], [3], [4], [5]. It occurs in patients with a wide range of ages, from newborns to adults, with varying degrees of severity, chronicity, and physiological states. It is associated with a higher risk of poor neurological outcome, cognitive disturbances, decreased functional status, and memory deficits [5], [6], [7].

There have been several mechanisms to explain the development of post-hemorrhagic hydrocephalus, mostly by alterations in cerebrospinal fluid (CSF) dynamics; however, its pathophysiology is multifactorial [8], [9], [10], [11], [12]. In general, hydrocephalus develops due to obstructive mechanisms as a consequence of blood products or adhesions that block CSF circulation within ventricles and cisterns, or of impairment of CSF absorption at the arachnoid granulations [3], [13], [14].

Ventriculoperitoneal (VP) shunt surgery is a common neurosurgical procedure for the management of post-hemorrhagic hydrocephalus conditions including SAH, SDH, ICH, and IVH. Although VP shunting of CSF reduces the morbidity and mortality of hydrocephalus considerably, it is associated with myriad potential complications that may require multiple surgical procedures during a patient's lifetime [15], [16], [17], [18]. Causes for shunt complications and shunt failures include shunt infection, overdrainage, mechanical obstruction, equipment failure, and disconnection [15], [16], [17], [18]. Thus, shunt system removal, replacement, or revision is inevitable in patients with hydrocephalus [17], [19].

Previously, we have shown that shunt survival is significantly associated with etiology and hydrocephalus type in adult hydrocephalus patients [20]. In addition, the sub-analysis of the study indicated that the etiology of hydrocephalus affects shunt revision in adult obstructive hydrocephalus [21]. Moreover, the analysis of relevant risk factors for shunt survival demonstrated that, gender, tumor histology, and a procedure prior to shunt placement were independent risk factors for shunt survival in hydrocephalus patients with intracranial tumors [22]. However, the demographic factors that influence shunt survival or the risk of shunt complications have yet to be fully investigated for the adult patients with hemorrhage-related hydrocephalus. This report was a sub-analysis from a larger retrospective clinical study that evaluated VP shunt surgery and the incidence of shunt revision in adult patients with hemorrhage-related hydrocephalus.

Section snippets

Materials and methods

The details of the retrospective study design, patient selection, and inclusion or exclusion criteria of patients were described in detail previously [20]. Briefly, using the institutional database (MD Analyze, Medtech Global Ltd., South Melbourne, Victoria, Australia), patients treated at the Louisiana State University Health Sciences Center – Shreveport (LSUHSC – S) between October 1990 and October 2009 were initially identified for the study. Patients 18 years or older who underwent primary

Results

A total of 1658 patients who underwent treatment for hydrocephalus were initially screened and 956 patients with VP shunt placement were identified. Of the 956 patients, 273 were excluded, because these patients had initial shunt surgery in their pediatric (<18) years. The 683 of the 956 patients were adults (>18 years) at the time of the initial shunt placement. Of the 683 adult patients, 133 were treated with VP shunt surgery for post-hemorrhagic hydrocephalus at the time of this analysis and

Discussion

Complications and failures of VP shunt surgery have been studied predominantly in the pediatric hydrocephalus population. Very few studies, however, focused on evaluating shunt complications and relevant risk factors for shunt failures in adult hydrocephalus patients [17], [23], [24], [25]. Evidence from these studies suggests that similar to the pediatric patients, adult patients with hydrocephalus experience relatively high shunt failures requiring neurosurgical interventions [24]. Thus, the

Conclusion

This retrospective study evaluated the management of post-hemorrhagic hydrocephalus in 133 adult patients. Specifically, the study examined various perioperative risk factors, including gender, ethnicity, type of post-hemorrhagic condition and hydrocephalus type affecting the overall incidence of shunt revisions and median time to first shunt failure in adult patients with post-hemorrhagic hydrocephalus. No significant association was seen between the perioperative variables and the incidence

Acknowledgments

Statistical assistance provided by Dr. Runhua Shi, MD, PhD is gratefully acknowledged. The author is thankful to Dr. Papireddy Bollam, MD, for his assistance in the data collection and patients’ chart review. The author gratefully acknowledge Mr. Pradheeth Reddy for his work in editing and proof reading of the manuscript.

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Pilot study on high-resolution radiological methods for the analysis of cerebrospinal fluid (CSF) shunt valves
2023, Zeitschrift fur Medizinische Physik
Despite their life-saving capabilities, cerebrospinal fluid (CSF) shunts exhibit high failure rates, with a large fraction of failures attributed to the regulating valve. Due to a lack of methods for the detailed analysis of valve malfunctions, failure mechanisms are not well understood, and valves often have to be surgically explanted on the mere suspicion of malfunction.
The presented pilot study aims to demonstrate radiological methods for comprehensive analysis of CSF shunt valves, considering both the potential for failure analysis in design optimization, and for future clinical in-vivo application to reduce the number of required shunt revision surgeries. The proposed method could also be utilized to develop and support in situ repair methods (e.g. by lysis or ultrasound) of malfunctioning CSF shunt valves.
The primary methods described are contrast-enhanced radiographic time series of CSF shunt valves, taken in a favorable projection geometry at low radiation dose, and the machine-learning-based diagnosis of CSF shunt valve obstructions. Complimentarily, we investigate CT-based methods capable of providing accurate ground truth for the training of such diagnostic tools. Using simulated test and training data, the performance of the machine-learning diagnostics in identifying and localizing obstructions within a shunt valve is evaluated regarding per-pixel sensitivity and specificity, the Dice similarity coefficient, and the false positive rate in the case of obstruction free test samples.
Contrast enhanced subtraction radiography allows high-resolution, time-resolved, low-dose analysis of fluid transport in CSF shunt valves. Complementarily, photon-counting micro-CT allows to investigate valve obstruction mechanisms in detail, and to generate valid ground truth for machine learning-based diagnostics.
Machine-learning-based detection of valve obstructions in simulated radiographies shows promising results, with a per-pixel sensitivity >70%, per-pixel specificity >90%, a median Dice coefficient >0.8 and <10% false positives at a detection threshold of 0.5.
This ex-vivo study demonstrates obstruction detection in cerebro-spinal fluid shunt valves, combining radiological methods with machine learning under conditions compatible to future in-vivo application.
Results indicate that high-resolution contrast-enhanced subtraction radiography, possibly including time-series data, combined with machine-learning image analysis, has the potential to strongly improve the diagnostics of CSF shunt valve failures. The presented method is in principle suitable for in-vivo application, considering both measurement geometry and radiological dose. Further research is needed to validate these results on real-world data and to refine the employed methods.
In combination, the presented methods enable comprehensive analysis of valve failure mechanisms, paving the way for improved product development and clinical diagnostics of CSF shunt valves.
Development of an In Vitro Hemorrhagic Hydrocephalus Model for Functional Evaluation of Magnetic Microactuators Against Shunt Obstructions
2021, World Neurosurgery
Citation Excerpt :
This has been attributed to the proximity between the brain parenchyma and VC.12 Specifically, VC obstructions secondary to intraluminal blood clot formation are common following VP shunting in the management of PHH.1,3,6,9 In our experiment, intraluminal hematoma obstructions developed in 4 of 5 control shunts, including 3 obstructions within the VC and 3 within the valve-DC component.
Occlusion of ventriculoperitoneal shunts placed after intraventricular hemorrhage occurs frequently. The objective of this study was to develop a hemorrhagic hydrocephalus model to assess the ability of an oscillating microactuator within the ventricular catheter (VC) to prevent shunt obstruction.
An in vitro hydrocephalus model with extreme risk of shunt obstruction was created. Phosphate-buffered saline, blood, and thrombin were driven through ventriculoperitoneal shunts for 8 hours. Five VCs were fitted with a microactuator and compared with 5 control VCs. The microactuator was actuated by an external magnetic field for 30 minutes. Pressure within the imitation lateral ventricle was measured.
In the 5 control shunts, 6 obstructions developed (3 VC, 3 valve-distal catheter) compared with 1 obstruction (VC) in the 5 microactuator shunts. In the control and microactuator groups, the median volume exiting the shunts in 8 hours was 30 mL versus 256 mL. Median time to reach an intraventricular pressure of 40 mm Hg (13.8 minutes vs. >8 hours), median total time >40 mm Hg (6.2 hours vs. 0.0 hours), and median maximum pressure (192 mm Hg vs. 36 mm Hg) were significantly improved in the microactuator group (P < 0.01).
In addition to protecting the VC, the microactuator appeared to prevent hematoma obstructing the valve or distal catheter, resulting in a much longer duration of low intraventricular pressures. A microactuator activated by placing the patient's head in an external magnetic field could reduce shunt obstructions in hemorrhagic hydrocephalus.
Patient Risk Factors Associated With 30- and 90-Day Readmission After Ventriculoperitoneal Shunt Placement for Idiopathic Normal Pressure Hydrocephalus in Elderly Patients: A Nationwide Readmission Study
2021, World Neurosurgery
Citation Excerpt :
Similarly, in a retrospective study of 14,455 patients (80% of cohort age >18 years) with all-cause hydrocephalus treated by VP shunt surgery from the Office of Statewide Health Planning and Development, Wu et al. showed through a multivariate analysis that male sex was independently associated with increased risk of subsequent readmission for shunt complication (hazard ratio: 1.1, 95% CI: 1.03–1.2).10 Conversely, in a retrospective study of 133 adult patients undergoing ventriculoperitoneal shunt surgery at the Louisiana State University Health Sciences Center-Shreveport, Reddy et al. found that sex was not associated with shunt revision.12 Therefore, although increasing age may not be as important a risk-factor in the elderly population comprising a majority of iNPH patients, there may be an underlying sex disparity that warrants further investigation.
For idiopathic normal pressure hydrocephalus (iNPH), risk stratifying patients and identifying those who are likely to fare well after ventriculoperitoneal shunt (VP) surgery may help improve quality of care and reduce unplanned readmissions. The aim of this study was to investigate the drivers of 30- and 90-day readmissions after VP shunt surgery for iNPH in elderly patients.
The Nationwide Readmission Database, years 2013 to 2015, was queried. Elderly patients (≥65 years old) undergoing VP shunt surgery were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Unique patient linkage numbers were used to follow patients and identify 30- and 31- to 90-day readmission rates. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31 to 90 days (90-R).
We identified 7199 elderly patients undergoing VP shunt surgery for iNPH. A total of 1413 (19.6%) patients were readmitted (30-R: n = 812 [11.3%] vs. 90-R: n = 601 [8.3%] vs. Non-R: n = 5786). The most prevalent 30- and 90-day complications seen among the readmitted cohort were mechanical complication of nervous system device implant (30-R: 16.1%, 90-R: 12.4%), extracranial postoperative infection (30-R: 10.4%, 90-R: 7.0%), and subdural hemorrhage (30-R: 6.0%, 90-R: 16.4%). On multivariate regression analysis, age, diabetes, and renal failure were independently associated with 30-day readmission; female sex, and 26th to 50th household income percentile were independently associated with reduced likelihood of 90-day readmission. Having any complication during the index admission independently associated with both 30- and 90-day readmission.
In this study, we identify the most common drivers for readmission for elderly patients with iNPH undergoing VP shunt surgery.
Lumboperitoneal shunts for the treatment of idiopathic normal pressure hydrocephalus
2021, Journal of Clinical Neuroscience
The standard of care for idiopathic normal pressure hydrocephalus (iNPH) is placement of a ventriculoperitoneal (VP) shunt. However, VP shunts require intracranial intervention and are associated with notable postoperative complications, with some groups reporting complication rates for VP shunts ranging from 17 to 33%, along with failure rates up to 17.7%. Lumboperitoneal (LP) shunts are an alternative for cerebrospinal fluid diversion that do not require intracranial surgery, thus providing utility in patients where intracranial surgery is not possible or preferred. Here we retrospectively reviewed our 25 patients with LP horizontal-vertical (LP-HV) shunts placement for initial treatment for iNPH from 2014 to 2019. All patients had preoperative gait dysfunction, 16 (64%) had urinary incontinence, and 21 (84%) exhibited cognitive insufficiency. Two weeks post-shunt placement, 23/25 (92%) patients demonstrated improvement in gait, 11/16 (68%) had improvement in incontinence, and 14/21 (66%) had improvement cognitive insufficiency. At six months or greater follow up 13/20 (65%) had improvement in gait, 7/15 (47%) showed improvement in incontinence, and 11/15 (73%) demonstrated improvement in cognitive function. Six patients (24%) required at least one revision of the LP shunt. Shunt malfunctions resulted from CSF leak in one patient, shunt catheter migration in two patients, peritoneal catheter pain in one patient, and clinical symptoms for overdrainage in two patients. Thus, we demonstrate that LP-HV shunt placement is safe and efficacious alternative to VP shunting for iNPH, resulting in notable symptomatic improvement and low risk of overdrainage, and may be considered for patients where cranial approaches should be avoided.
Rate and Risk Factors of Early Ventriculoperitoneal Shunt Revision: A Five-Year Retrospective Analysis of a Referral Center
2020, World Neurosurgery
Cerebral shunts are the mainstay treatment of hydrocephalus. Because most previous studies have focused on factors related to long-term outcomes of shunt surgery, we aimed to assess the rates and causes of 30-day ventriculoperitoneal shunt (VPS) failure in a single referral center over 5 years in both adult and pediatric patients.
Patients who underwent VPS surgery from February 2012 to February 2017 in Ghaem Teaching Hospital, Mashhad, Iran were evaluated retrospectively through clinical history, operative reports, imaging studies, and follow-up notes. Data of 12 possible factors related to shunt failure were collected comprising age, gender, household income, level of education, cause of hydrocephalus, causes of revision, type of failure, anatomic site, duration of operation, time of surgery, surgeons' level of expertise, and Glasgow Coma Scale (GCS) score.
Among 403 VPS placements, 121 VPS revisions were performed, and 82 eligible patients were included in the study (57.3% male and 42.7% female). The 30-day shunt failure rate was 24.4% among all revisions. Obstruction and malposition were the most common causes of early revisions. Six factors were statistically significant in the univariate analysis. After adjustment in a logistic regression model, 2 factors, namely surgeons' level of expertise (odds ratio, 10.33; 95% confidence interval, 1.08–98.80) and anatomic site of the shunt (odds ratio, 10.28; 95% confidence interval, 1.21–87.35) were associated with early shunt revision.
Shunt surgeries performed by junior residents and shunts placed in the frontal site were associated with early shunt failure.
Early Readmission After Ventricular Shunting in Adults with Hydrocephalus: A Nationwide Readmission Database Analysis
2019, World Neurosurgery
Citation Excerpt :
Failure rates in adults are generally lower (17%–33%)7-15 and predominantly reflect revisions within the first 6 months after insertion. Single-institution analyses suggest that 9.1%–26% of adults required revision during the first 6 months,7-15 whereas the 2 state-based data sets suggest a 15%–21% 1-year adult revision rate.7,11 We seek to derive an estimate of shunt failure using a large cohort of adults with hydrocephalus via the Nationwide Readmissions Database (NRD).
Ventricular shunting is one of the primary modalities for addressing hydrocephalus in both children and adults. Despite advances in shunt technology and surgical practices, shunt failure is a persistent challenge for neurosurgeons, and shunt revisions account for a substantial proportion of all shunt-related procedures. There are a wealth of studies elucidating failure patterns and patient demographics in pediatric cohorts; however, data in adults are less uniform. We sought to determine the rates of all-cause and shunt failure readmission in adults who underwent the insertion of a ventricular shunt.
We queried the Nationwide Readmissions Database from 2010 to 2014 to evaluate new ventricular shunts placed in adults with hydrocephalus. We sought to determine the rates of all-cause and shunt revision-related readmissions and to characterize factors associated with readmissions. We analyzed predictors including patient demographics, hospital characteristics, shunt type, and hydrocephalus cause.
Analysis included 24,492 initial admissions for shunt placement in patients with hydrocephalus. Of patients, 9.17% required a shunt revision within the first 6 months; half of all revisions occurred within the first 41 days. There were 4044 (16.50%) 30-day and 5758 (28.8%) 90-day all-cause readmissions. In multivariable analysis, patients with a ventriculopleural shunt, Medicare insurance, and younger age had increased likelihood for shunt revision. Notable predictors for all-cause readmission were insurance type, length of hospitalization, age, comorbidities, and hydrocephalus cause.
Most shunt revisions occurred during the first 2 months. Readmissions occurred frequently. We identified patient factors that were associated with all-cause and shunt failure readmissions.

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Ventriculoperitoneal shunt surgery and the incidence of shunt revision in adult patients with hemorrhage-related hydrocephalus

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Acknowledgments

Surg Neurol

World Neurosurg

Surg Neurol

J Clin Neurosci

Ventriculoperitoneal shunting after aneurysmal subarachnoid hemorrhage: analysis of the indications, complications, and outcome with a focus on patients with borderline ventriculomegaly

Neurosurgery

Chronic hydrocephalus in elderly patients following subarachnoid hemorrhage

Surg Neurol

Hydrocephalus in the adult following spontaneous subarachnoid haemorrhage

Brain

Intraventricular hemorrhage and hydrocephalus after spontaneous intracerebral hemorrhage: results from the STICH trial

Acta Neurochir Suppl

Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage

Neurosurgery

Factors associated with hydrocephalus after aneurysmal subarachnoid hemorrhage

Neurosurgery

A proposed model of cerebrospinal fluid circulation: observations with radionuclide cisternography

AJNR Am J Neuroradiol

Distribution of cisternal blood in patients with acute hydrocephalus after subarachnoid hemorrhage

Ann Neurol

Clinical study of cerebrospinal fluid dynamics using 111In-DTPA SPECT in patients with subarachnoid hemorrhage

Neurol Med Chir (Tokyo)

Disturbances of cerebrospinal fluid circulation during the acute stage of subarachnoid hemorrhage

Neurosurgery

Cerebrospinal fluid dynamics and hydrocephalus after experimental subarachnoid hemorrhage

Neurosurgery

The effect of protein and blood cells on the flow-pressure characteristics of shunts

Neurosurgery

Recent research into the nature of cerebrospinal fluid formation and absorption

J Neurosurg

Epidemiology, prevention and management of ventriculoperitoneal shunt infections in children

Pediatr Neurosurg