Posthemorrhagic hydrocephalus and shunts: what are the predictors of multiple revision surgeries?

Clinical article

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Object

Cerebrospinal fluid shunts in patients with posthemorrhagic hydrocephalus are prone to failure, with some patients at risk for multiple failures. The objective of this study was to identify factors leading to multiple failures.

Methods

The authors performed a retrospective analysis of cases of posthemorrhagic hydrocephalus requiring neurosurgical intervention between 1982 and 2010.

Results

In the 109 cases analyzed, 54% of the patients were male, their mean birth weight was 1223 g, and their mean head circumference 25.75 cm. The mean duration of follow-up was 6 years, and 9 patients died. Grade III intraventricular hemorrhage was seen in 47.7% and Grade IV in 43.1%. Initial use of a ventricular access device was needed in 65 patients (59.6%), but permanent CSF shunting was needed in 104 (95.4%). A total of 454 surgical procedures were performed, including 304 shunt revisions in 78 patients (71.6%). Detailed surgical notes were available for 261 of these procedures, and of these, 51% were proximal revisions, 13% distal revisions, and 17% total shunt revisions. Revision rates were not affected by catheter type, patient sex, presence of congenital anomalies, or type of hydrocephalus. Age of less than 30 days at the initial procedure was associated with decreased survival of the first shunt. Regression analysis revealed that lower estimated gestational age (EGA) and obstructive hydrocephalus were significant predictors of multiple shunt revisions.

Conclusions

We found a high rate of need for permanent CSF shunts (95.4%) in patients with posthemorrhagic hydrocephalus. Shunt revision was required in 71.6% of patients, with those with lower birth weight and EGA at a higher risk for revisions.

Abbreviations used in this paper:EGA = estimated gestational age; IVH = intraventricular hemorrhage; LSU = Louisiana State University; VAD = ventricular access device.

Article Information

Address correspondence to: Anil Nanda, M.D., Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana 71130. email: ananda@lsuhsc.edu.

This article contains some figures that are displayed in color online but in black-and-white in the print edition.

Parts of this study were presented orally at the AANS/CNS Section on Pediatric Neurological Surgery at the 79th Annual Scientific Meeting of the AANS in Denver, Colorado, April 2011.

Please include this information when citing this paper: published online October 26, 2012; DOI: 10.3171/2012.8.PEDS11296.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Flowchart showing the patient selection in the study. For the purpose of data analysis, the patients included in the boxes outlined with bold lines were included.

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    Survival analysis for the initial shunt. Comparison of shunt survival in patients stratified by initial procedure (shunt placement vs VAD placement). Shunt survival was much poorer when the shunt was placed after a reservoir (VAD) (red line) than when the shunt was placed as the initial device (purple line). Open circles indicate censored data points.

  • View in gallery

    Survival analysis for the initial shunt stratified by patient age at placement (< 30 days, indicated by purple line, vs ≥ 30 days, indicated by red line). Open circles indicate censored data points.

  • View in gallery

    Survival analysis for the initial shunt stratified by the patients' IVH grade. The black line indicates Grades I and II; the red line, Grades III and IV. Open circles indicate censored data points.

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