Shunt survival after failed endoscopic treatment of hydrocephalus

Clinical article

Benjamin C. Warf Department of Neurosurgery, Children's Hospital Boston;
Department of Global Health and Social Medicine,

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 M.D.
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Salman Bhai Harvard Medical School, Boston, Massachusetts;

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Abhaya V. Kulkarni Department of Neurosurgery, Hospital for Sick Children and University of Toronto, Ontario, Canada;

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 M.D., Ph.D.
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John Mugamba CURE Children's Hospital of Uganda, Mbale, Uganda

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Object

It is not known whether previous endoscopic third ventriculostomy (ETV) affects the risk of shunt failure. Different epochs of hydrocephalus treatment at the CURE Children's Hospital of Uganda (CCHU)—initially placing CSF shunts in all patients, then attempting ETV in all patients, and finally attempting ETV combined with choroid plexus cauterization (CPC) in all patients—provided the opportunity to assess whether prior endoscopic surgery affected shunt survival.

Methods

With appropriate institutional approvals, the authors reviewed the CCHU clinical database to identify 2329 patients treated for hydrocephalus from December 2000 to May 2007. Initial ventriculoperitoneal (VP) shunt placement was performed in 900 patients under one of three circumstances: 1) primary nonselective VP shunt placement with no endoscopy (255 patients); 2) VP shunt placement at the time of abandoned ETV attempt (with or without CPC) (370 patients); 3) VP shunt placement subsequent to a completed but failed ETV (with or without CPC) (275 patients). We analyzed time to shunt failure using the Kaplan-Meier method to construct survival curves, Cox proportional hazards regression modeling, and risk-adjusted analyses to account for possible confounding differences among these groups.

Results

Shunt failure occurred in 299 patients, and the mean duration of follow-up for the remaining 601 was 28.7 months (median 18.8, interquartile range 4.1–46.3). There was no significant difference in operative mortality (p = 0.07 by log-rank and p = 0.14 by Cox regression adjusted for age and hydrocephalus etiology) or shunt infection (p = 0.94, log-rank) among the 3 groups. There was no difference in shunt survival between patients treated with primary shunt placement and those who underwent shunt placement at the time of an abandoned ETV attempt (adjusted hazard ratio [HR] 1.14, 95% CI 0.86–1.51, p = 0.35).

Those who underwent shunt placement after a completed but failed ETV (with or without CPC) had a lower risk of shunt failure (p = 0.008, log-rank), with a hazard ratio (adjusted for age at shunting and etiology) of 0.72 (95% CI 0.53–0.98), p = 0.03, compared with those who underwent primary shunt placement without endoscopy; but this was observed only in patients with postinfectious hydrocephalus (PIH) (adjusted HR 0.55, 95% CI 0.36–0.85, p = 0.007), and no effect was apparent for hydrocephalus of noninfectious etiologies (adjusted HR 0.98, 95% CI 0.64–1.50, p = 0.92). Improved shunt survival after failed ETV in the PIH group may be an artifact of selection arising from the inherent heterogeneity of ventricular damage within that group, or a consequence of the timing of shunt placement. The anticipated benefit of CPC in preventing future ventricular catheter obstruction was not observed.

Conclusions

A paradigm for infant hydrocephalus involving intention to treat by ETV with or without CPC had no adverse effect on mortality or on subsequent shunt survival or infection risk. This study failed to demonstrate a positive effect of prior ETV or CPC on shunt survival.

Abbreviations used in this paper:

CCHU = CURE Children's Hospital of Uganda; CPC = choroid plexus cauterization; ETV = endoscopic third ventriculostomy; HR = hazard ratio; PIH = postinfectious hydrocephalus; VP = ventriculoperitoneal.
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  • 1

    Dickerman RD, , McConathy WJ, , Morgan J, , Stevens QE, , Jolley JT, & Schneider S, et al.: Failure rate of frontal versus parietal approaches for proximal catheter placement in ventriculoperitoneal shunts: revisited. J Clin Neurosci 12:781783, 2005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Gallo P, , Szathmari A, , De Biasi S, & Mottolese C: Endoscopic third ventriculostomy in obstructive infantile hydrocephalus: remarks about the so-called ‘unsuccessful cases’. Pediatr Neurosurg 46:435441, 2010

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

    Ginsberg HJ, , Drake JM, , Peterson TM, & Cobbold RS: Recanalization of obstructed cerebrospinal fluid ventricular catheters using ultrasonic cavitation. Neurosurgery 59:4 Suppl 2 ONS403ONS412, 2006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Gnanalingham KK, , Lafuente J, , Brew S, , Thompson D, , Harkness W, & Hayward R: Percutaneous coagulation of choroid plexus to unblock the ventricular catheter using the Seldinger technique: preliminary report. Surg Neurol 64:440443, 2005

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

    Kestle JR, , Drake JM, , Cochrane DD, , Milner R, , Walker ML, & Abbott R III, et al.: Lack of benefit of endoscopic ventriculoperitoneal shunt insertion: a multicenter randomized trial. J Neurosurg 98:284290, 2003

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

    Kleinbaum DG, , Kupper LL, & Muller KE: Applied Regression Analysis and Other Multivariable Methods ed 2 Belmont, CA, Duxbury Press, 1988. 209214

  • 7

    Kulkarni AV, , Drake JM, , Kestle JR, , Mallucci CL, , Sgouros S, & Constantini S: Predicting who will benefit from endoscopic third ventriculostomy compared with shunt insertion in childhood hydrocephalus using the ETV Success Score. Clinical article. J Neurosurg Pediatr 6:310315, 2010. (Erratum in J Neurosurg Pediatr 7:221, 2011)

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

    Kulkarni AV, , Warf BC, , Drake JM, , Mallucci CL, , Sgouros S, & Constantini S: Surgery for hydrocephalus in sub-Saharan Africa versus developed nations: a risk-adjusted comparison of outcome. Childs Nerv Syst 26:17111717, 2010

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

    Oi S, & Di Rocco C: Proposal of “evolution theory in cerebrospinal fluid dynamics” and minor pathway hydrocephalus in developing immature brain. Childs Nerv Syst 22:662669, 2006

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

    Pang D, & Grabb PA: Accurate placement of coronal ventricular catheter using stereotactic coordinate-guided free-hand passage. Technical note. J Neurosurg 80:750755, 1994

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Sekhar LN, , Moossy J, & Guthkelch AN: Malfunctioning ventriculoperitoneal shunts. Clinical and pathological features. J Neurosurg 56:411416, 1982

  • 12

    Shim KW, , Kim DS, & Choi JU: Simultaneous endoscopic third ventriculostomy and ventriculoperitoneal shunt for infantile hydrocephalus. Childs Nerv Syst 24:443451, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Warf BC: Comparison of 1-year outcomes for the Chhabra and Codman Hakim Micro Precision shunt systems in Uganda: a prospective study in 195 children. J Neurosurg 4 Suppl 102:358362, 2005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Warf BC: Comparison of endoscopic third ventriculostomy alone and combined with choroid plexus cauterization in infants younger than 1 year of age: a prospective study in 550 African children. J Neurosurg 6 Suppl 103:475481, 2005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Warf BC: Hydrocephalus in Uganda: predominance of infectious origin and primary management with endoscopic third ventriculostomy. J Neurosurg 1 Suppl 102:115, 2005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Warf BC, & Campbell JW: Combined endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC) as primary treatment of hydrocephalus for infants with myelomeningocele: long-term results of a prospective intention to treat study in 115 African infants. Clinical article. J Neurosurg Pediatr 2:310316, 2008

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Warf BC, , Dagi AR, , Nsbuga B, & Schiff SJ: Five-year survival and outcome of treatment for post-infectious hydrocephalus in Ugandan infants. Clinical article. J Neurosurg Pediatr 8:502508, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Warf BC, , Dewan M, & Mugamba J: Management of Dandy-Walker Complex-associated infant hydrocephalus by combined endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC). Clinical article. J Neurosurg Pediatr 8:377383, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Warf BC, & Kulkarni AV: Intraoperative assessment of cerebral aqueduct patency and cisternal scarring: impact on success of endoscopic third ventriculostomy in 403 African children. Clinical article. J Neurosurg Pediatr 5:204209, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Warf BC, , Mugamba J, & Kulkarni AV: Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus in Uganda: report of a scoring system that predicts success. Clinical article. J Neurosurg Pediatr 5:143148, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Warf BC, , Stagno V, & Mugamba J: Encephalocele in Uganda: Ethnic variation in lesion location, endoscopic management of hydrocephalus, and survival in 110 consecutive children. Clinical article. J Neurosurg Pediatr 7:8893, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Warf BC, , Tracy S, & Mugamba J: Long-term outcome for combined endoscopic third ventriculostomy alone or in combination with choroid plexus cauterization compared with choroid plexus cauterization for congenital aqueductal stenosis in African infants. Clinical article. J Neurosurg Pediatr 10:108111, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Warf BC, , Wright EJ, & Kulkarni AV: Factors affecting survival of infants with myelomeningocele in southeastern Uganda. Clinical article. J Neurosurg Pediatr 7:127133, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Wewer C, , Seibt A, , Wolburg H, , Greune L, , Schmidt MA, & Berger J, et al.: Transcellular migration of neutrophil granulocytes through the blood-cerebrospinal fluid barrier after infection with Streptococcus suis. J Neuroinflammation 8:51, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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