Predictors of fast and ultrafast shunt failure in pediatric hydrocephalus: a Hydrocephalus Clinical Research Network study

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  • 1 Department of Neurosurgery, University of Washington, Seattle Children’s Hospital, Seattle, Washington;
  • | 2 Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children’s Medical Center, University of Utah, Salt Lake City, Utah;
  • | 3 Department of Neurosurgery, University of Calgary, Alberta, Canada;
  • | 4 Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada;
  • | 5 Section of Pediatric Neurosurgery, Division of Neurosurgery, Children’s Hospital of Alabama, University of Alabama–Birmingham, Alabama;
  • | 6 Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas;
  • | 7 Division of Pediatric Neurosurgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee;
  • | 8 Department of Neurosurgery, Nationwide Children’s Hospital, Columbus, Ohio;
  • | 9 Department of Neurosurgery, St. Louis Children’s Hospital, Washington University in St. Louis, Missouri;
  • | 10 University of British Columbia Department of Surgery, Division of Neurosurgery, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada;
  • | 11 Department of Pediatrics, University of Washington, Seattle Children’s Hospital, Seattle, Washington;
  • | 12 Division of Neurosurgery, Children’s Hospital of Pittsburgh, Pennsylvania;
  • | 13 Division of Neurosurgery, Children’s Hospital Los Angeles, California;
  • | 14 Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado; and
  • | 15 Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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OBJECTIVE

The primary objective of this study was to use the prospective Hydrocephalus Clinical Research Network (HCRN) registry to determine clinical predictors of fast time to shunt failure (≤ 30 days from last revision) and ultrafast time to failure (≤ 7 days from last revision).

METHODS

Revisions (including those due to infection) to permanent shunt placements that occurred between April 2008 and November 2017 for patients whose entire shunt experience was recorded in the registry were analyzed. All registry data provided at the time of initial shunt placement and subsequent revision were reviewed. Key variables analyzed included etiology of hydrocephalus, age at time of initial shunt placement, presence of slit ventricles on imaging at revision, whether the ventricles were enlarged at the time of revision, and presence of prior fast failure events. Univariable and multivariable analyses were performed to find key predictors of fast and ultrafast failure events.

RESULTS

A cohort of 1030 patients with initial shunt insertions experienced a total of 1995 revisions. Of the 1978 revision events with complete records, 1216 (61.5%) shunts remained functional for more than 1 year, and 762 (38.5%) failed within 1 year of the procedure date. Of those that failed within 1 year, 423 (55.5%) failed slowly (31–365 days) and 339 (44.5%) failed fast (≤ 30 days). Of the fast failures, 131 (38.6%) were ultrafast (≤ 7 days). In the multivariable analysis specified a priori, etiology of hydrocephalus (p = 0.005) and previous failure history (p = 0.011) were independently associated with fast failure. Age at time of procedure (p = 0.042) and etiology of hydrocephalus (p = 0.004) were independently associated with ultrafast failure. These relationships in both a priori models were supported by the data-driven multivariable models as well.

CONCLUSIONS

Neither the presence of slit ventricle syndrome nor ventricular enlargement at the time of shunt failure appears to be a significant predictor of repeated, rapid shunt revisions. Age at the time of procedure, etiology of hydrocephalus, and the history of previous failure events seem to be important predictors of fast and ultrafast shunt failure. Further work is required to understand the mechanisms of these risk factors as well as mitigation strategies.

ABBREVIATIONS

CPC = choroid plexus coagulation; ETV = endoscopic third ventriculostomy; EVD = external ventricular drain; HCRN = Hydrocephalus Clinical Research Network; IVH = intraventricular hemorrhage.

Supplementary Materials

    • Supplemental Tables 1–3 (PDF 425 KB)
Figure from Coblentz et al. (pp 346–356).

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