Effect of fixed-setting versus programmable valve on incidence of shunt revision after ventricular shunting for idiopathic normal pressure hydrocephalus

Restricted access

OBJECTIVE

Although ventricular shunting is an effective therapy for idiopathic normal pressure hydrocephalus (iNPH), the effect of shunt valve type on the incidence of revision surgery is not well defined. To address this issue, shunt revision rates between patients with iNPH receiving a fixed-setting valve (FSV) versus a programmable valve (PV) were compared.

METHODS

Patients with iNPH treated with ventricular shunting between 2001 and 2017 were included for analysis. The incidence of shunt revision was noted and risk factors for revision were identified using a Cox proportional hazards model. Costs associated with admission for ventricular shunt procedures were obtained from the Vizient national database.

RESULTS

There were 348 patients included for analysis, with 98 patients (28.1%) receiving a PV. Shunt revision occurred in 73 patients (21.0%), with 12 patients (3.4%) undergoing multiple revisions. Overall revision rates were lower in patients receiving a PV (13.3% vs 24.0%; p = 0.027), as was the incidence of multiple revisions (0.0% vs 4.8%; p = 0.023). Patients with initial placement of an FSV were also more likely to undergo valve exchange during follow-up (12.4% vs 2.0%; p = 0.003). Patients with a PV were less likely to undergo revision due to persistent symptoms without obstruction (2.0% vs 8.8%; p = 0.031) and distal obstruction (1.0% vs 6.8%; p = 0.030). In a multivariate Cox proportional hazards model, initial placement of a PV was associated with reduced risk of revision due to persistent symptoms without obstruction (OR 0.27, 95% CI 0.04–0.93; p = 0.036). PVs were associated with more frequent shunt series (1.3 vs 0.6; p < 0.001) and head CT scans (3.6 vs 2.7; p = 0.038) during follow-up. There was no significant difference in mean total costs between patients receiving an FSV and a PV ($24,282.50 vs $24,396.90; p = 0.937).

CONCLUSIONS

The authors’ results suggest that PVs lead to reduced rates of shunt revision in patients with iNPH, and decreased risk of revision due to persistent symptoms of iNPH, thereby justifying the higher upfront cost of PVs despite similar overall treatment costs between these devices.

ABBREVIATIONS BMI = body mass index; FSV = fixed-setting valve; iNPH = idiopathic normal pressure hydrocephalus; PV = programmable valve.

Article Information

Correspondence Benjamin D. Elder: Mayo Clinic, Rochester, MN. elder.benjamin@mayo.edu.

INCLUDE WHEN CITING Published online June 7, 2019; DOI: 10.3171/2019.3.JNS183077.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Kaplan-Meier curves depicting time to all revisions (A and B), revision due to shunt nonresponsiveness (C), and distal obstruction (D). p values were obtained from log-rank tests. Figure is available in color online only.

  • View in gallery

    Temporal trends in PV utilization and incidence of revision surgery. Results of linear regression analyses demonstrating changes in the annual rate of PV utilization (A), incidence of revision surgery due to all causes (B), and incidence of revision surgery due to shunt nonresponsiveness over time (C). Shaded areas denote 95% CIs. Figure is available in color online only.

References

  • 1

    Agarwal NKashkoush AMcDowell MMLariviere WRIsmail NFriedlander RM: Comparative durability and costs analysis of ventricular shunts. J Neurosurg 130:125212592019

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Cabral DBeach TGVedders LSue LIJacobson SMyers K: Frequency of Alzheimer’s disease pathology at autopsy in patients with clinical normal pressure hydrocephalus. Alzheimers Dement 7:5095132011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Dabdoub CBDabdoub CFChavez MVillarroel JFerrufino JLCoimbra A: Abdominal cerebrospinal fluid pseudocyst: a comparative analysis between children and adults. Childs Nerv Syst 30:5795892014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Delwel EJde Jong DADammers RKurt Evan den Brink WDirven CM: A randomised trial of high and low pressure level settings on an adjustable ventriculoperitoneal shunt valve for idiopathic normal pressure hydrocephalus: results of the Dutch evaluation programme Strata shunt (DEPSS) trial. J Neurol Neurosurg Psychiatry 84:8138172013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Farahmand DSæhle TEide PKTisell MHellström PWikkelsö C: A double-blind randomized trial on the clinical effect of different shunt valve settings in idiopathic normal pressure hydrocephalus. J Neurosurg 124:3593672016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Hebb AOCusimano MD: Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome. Neurosurgery 49:116611862001

  • 7

    Mori EIshikawa MKato TKazui HMiyake HMiyajima M: Guidelines for management of idiopathic normal pressure hydrocephalus: second edition. Neurol Med Chir (Tokyo) 52:7758092012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Patwardhan RVNanda A: Implanted ventricular shunts in the United States: the billion-dollar-a-year cost of hydrocephalus treatment. Neurosurgery 56:1391452005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Pujari SKharkar SMetellus PShuck JWilliams MARigamonti D: Normal pressure hydrocephalus: long-term outcome after shunt surgery. J Neurol Neurosurg Psychiatry 79:128212862008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Relkin NMarmarou AKlinge PBergsneider MBlack PM: Diagnosing idiopathic normal-pressure hydrocephalus. Neurosurgery 57 (3 Suppl):S4S16 ii–v2005

    • Search Google Scholar
    • Export Citation
  • 11

    Sæhle TFarahmand DEide PKTisell MWikkelsö C: A randomized controlled dual-center trial on shunt complications in idiopathic normal-pressure hydrocephalus treated with gradually reduced or “fixed” pressure valve settings. J Neurosurg 121:125712632014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Williams MASharkey Pvan Doren DThomas GRigamonti D: Influence of shunt surgery on healthcare expenditures of elderly fee-for-service Medicare beneficiaries with hydrocephalus. J Neurosurg 107:21282007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 425 425 425
Full Text Views 37 37 37
PDF Downloads 27 27 27
EPUB Downloads 0 0 0

PubMed

Google Scholar