Using a burr hole valve prevents proximal shunt failure in infants and toddlers

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OBJECTIVE

Proximal malfunction is the most common cause of ventriculoperitoneal (VP) shunt failure in young children. In this study, the authors sought to determine factors that affect the migration rate of ventricular catheters in hydrocephalic children who undergo shunt implantation in the first 3 years of life.

METHODS

The authors reviewed the medical records and imaging studies of newly diagnosed and treated hydrocephalic children who were younger than 3 years. Patients who received VP shunt insertion through the parieto-occipital route were not included. In total, 78 patients were found who underwent VP shunt insertion between December 2006 and April 2017. Eighteen patients were excluded due to mortality, short follow-up period (< 1 year), and lack of imaging follow-up. The age, sex, etiology of hydrocephalus, initial length of ventricular catheter, valve type (burr hole vs non–burr hole), time to ventricular catheter migration, subsequent revision surgery, and follow-up period were analyzed. The diagnosis of a migrated ventricular catheter was made when serial imaging follow-up showed progressive withdrawal of the catheter tip from the ventricle, with the catheter shorter than 4 mm inside the ventricle, or progressive deviation of the ventricular catheter toward the midline or anterior ventricular wall.

RESULTS

Sixty patients were enrolled. The mean age was 5.1 months (range 1–30 months). The mean follow-up period was 50.9 months (range 13–91 months). Eight patients had ventricular catheter migration, and in 7 of these 8 patients a non–burr hole valve was used. In the nonmigration group, a non–burr hole valve was used in only 6 of the 52 patients. Six of the 8 patients with catheter migration needed second surgeries, which included removal of the shunt due to disconnection in 1 patient. The remaining 2 patients with shunt migration were followed for 91 and 46 months, respectively, without clinical and imaging changes. The authors found that patient age at catheter insertion, ventricular catheter length, and the use of a burr hole valve were protective factors against migration. After ventricular catheter length and patient age at catheter insertion were treated as confounding variables and adjusted with multivariable Weibull proportional hazards regression, the use of a burr hole valve shunt remained a protective factor.

CONCLUSIONS

The use of burr hole valves is a protective factor against ventricular catheter migration when the shunt is inserted via a frontal route. The authors suggest the use of a burr hole valve along with a frontal entry point in hydrocephalic children younger than 3 years to maintain long-term shunt function.

ABBREVIATIONS HR = hazard ratio; IICP = increased intracranial pressure; VP = ventriculoperitoneal.

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Article Information

Correspondence Meng-Fai Kuo: National Taiwan University Hospital, Taipei, Taiwan. mfkenator@gmail.com.

INCLUDE WHEN CITING Published online June 28, 2019; DOI: 10.3171/2019.4.PEDS18681.

C.H.H. and S.C.C. contributed equally to this work and share first authorship.

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.

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Figures

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    Design of study to compare the effect of valve types on the proximal shunt migration rate and shunt revision in hydrocephalic children younger than 3 years. CHD = congenital heart disease.

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    Illustrations showing various commonly used shunt configurations (A–D). The right angle devices are used at the frontal entry site with non–burr hole or flat-bottom valves which are located in the retroauricular region (A and B) or with the valve located at close proximity to the frontal entry site (C). A burr hole valve per se works as a right angle device at the frontal entry point (D). For all types of shunt designs, the valve provides the strongest anchoring force for the whole shunt apparatus (A–H, thick arrows). As children grow, the distance between the valves and the entry point increases (A–C) and the trajectory of the ventricular catheters first deviates medially or anteriorly (E–G, 1, short arrows). The ventricular catheters are then gradually pulled out of the ventricular system and cause migration (E–G, 2, long arrows). Only in cases in which a burr hole valve is used, the trajectory and length of the ventricular catheter can be fixed and anchored, reducing subsequent migration caused by the cranial growth or tethering of the distal component (H).

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    This 3-week-old girl underwent insertion of a non–burr hole type programmable VP shunt via right Kocher’s point due to posthemorrhagic hydrocephalus in the newborn period. Immediate postoperative skull radiographs show the length and trajectory of the ventricular catheter (A and B, double-headed arrows). Follow-up skull radiographs obtained 8 months after surgery show that the length and trajectory of the ventricular catheter became short and unsatisfactory due to head growth (C and D, double-headed arrows). T2-weighted MRI studies were performed just before shunt revision (E). The axial MR image shows that the trajectory of the ventricular catheter deviated toward the midline due to migration, and the ventricular catheter tip was located at the margin of the ventricular wall (E, left, black hollow arrow). The sagittal MR image shows that the tip migrated outward and was located at the anterior margin of the ventricular wall (E, right, white hollow arrow). An intraoperative photograph shows the previously used right angle connector has been pulled out from the bony margin at the entry point (F). Figure is available in color online only.

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    The clinical condition and subsequent management of the 8 patients with ventricular catheter migration. F/U = follow-up.

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