Hydrocephalus surveillance following CSF diversion: a modified Delphi study

David S. HershDivision of Neurosurgery, Connecticut Children’s, Hartford;
Department of Surgery, UConn School of Medicine, Farmington, Connecticut;

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Jonathan E. MartinDivision of Neurosurgery, Connecticut Children’s, Hartford;
Department of Surgery, UConn School of Medicine, Farmington, Connecticut;

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Ruth E. BristolDivision of Pediatric Neurosurgery, Department of Surgery, Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, Arizona;

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Samuel R. BrowdDepartment of Neurosurgery, University of Washington, Seattle Children’s Hospital, Seattle, Washington;

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Gerald GrantDepartment of Neurosurgery, Duke University, Durham, North Carolina;

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Nalin GuptaDepartments of Neurological Surgery and Pediatrics, University of California, San Francisco, California;

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Todd C. HankinsonDepartments of Neurosurgery and Pediatrics, University of Colorado School of Medicine/Children’s Hospital Colorado, Aurora, Colorado;

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Eric M. JacksonDepartment of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;

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John R. W. KestleDivision of Pediatric Neurosurgery, Primary Children’s Hospital, Salt Lake City;
Department of Neurosurgery, University of Utah, Salt Lake City, Utah;

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Mark D. KriegerDivision of Neurological Surgery, Department of Surgery, Children’s Hospital Los Angeles;
Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California;

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Abhaya V. KulkarniDivision of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada;

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Casey J. MaduraSection of Neurosurgery, Division of Pediatric Neurosciences, Helen DeVos Children’s Hospital, Grand Rapids, Michigan;

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Jonathan PindrikDivision of Pediatric Neurosurgery, Nationwide Children’s Hospital, Columbus;
Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio;

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Ian F. PollackDepartment of Neurosurgery, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;

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Jeffrey S. RaskinDivision of Pediatric Neurosurgery, Ann and Robert H. Lurie Children’s Hospital, Chicago;
Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois;

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Jay Riva-CambrinDepartment of Clinical Neurosciences, University of Calgary, Alberta, Canada;

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Curtis J. RozzelleDivision of Pediatric Neurosurgery, Children’s of Alabama, Birmingham;
Department of Neurosurgery, Heersink School of Medicine, University of Alabama at Birmingham, Alabama;

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Jodi L. SmithGoodman Campbell Brain and Spine, Peyton Manning Children’s Hospital at St. Vincent Ascension, Indianapolis, Indiana; and

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John C. Wellons IIIDepartment of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee

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OBJECTIVE

Long-term follow-up is often recommended for patients with hydrocephalus, but the frequency of clinical follow-up, timing and modality of imaging, and duration of surveillance have not been clearly defined. Here, the authors used the modified Delphi method to identify areas of consensus regarding the modality, frequency, and duration of hydrocephalus surveillance following surgical treatment.

METHODS

Pediatric neurosurgeons serving as institutional liaisons to the Hydrocephalus Clinical Research Network (HCRN), or its implementation/quality improvement arm (HCRNq), were invited to participate in this modified Delphi study. Thirty-seven consensus statements were generated and distributed via an anonymous electronic survey, with responses structured as a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). A subsequent, virtual meeting offered the opportunity for open discussion and modification of the statements in an effort to reach consensus (defined as ≥ 80% agreement or disagreement).

RESULTS

Nineteen pediatric neurosurgeons participated in the first round, after which 15 statements reached consensus. During the second round, 14 participants met virtually for review and discussion. Some statements were modified and 2 statements were combined, resulting in a total of 36 statements. At the conclusion of the session, consensus was achieved for 17 statements regarding the following: 1) the role of standardization; 2) preferred imaging modalities; 3) postoperative follow-up after shunt surgery (subdivided into immediate postoperative imaging, delayed postoperative imaging, routine clinical surveillance, and routine radiological surveillance); and 4) postoperative follow-up after an endoscopic third ventriculostomy. Consensus could not be achieved for 19 statements.

CONCLUSIONS

Using the modified Delphi method, 17 consensus statements were developed with respect to both clinical and radiological follow-up after a shunt or endoscopic third ventriculostomy. The frequency, modality, and duration of surveillance were addressed, highlighting areas in which no clear data exist to guide clinical practice. Although further studies are needed to evaluate the clinical utility and cost-effectiveness of hydrocephalus surveillance, the current study provides a framework to guide future efforts to develop standardized clinical protocols for the postoperative surveillance of patients with hydrocephalus. Ultimately, the standardization of hydrocephalus surveillance has the potential to improve patient care as well as optimize the use of healthcare resources.

ABBREVIATIONS

ETV = endoscopic third ventriculostomy; HCRN = Hydrocephalus Clinical Research Network; HCRNq = HCRN implementation/quality improvement arm.
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Images from Oushy et al. (pp 195–202).

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