Reliability of the radiopharmaceutical shunt flow study for the detection of a CSF shunt malfunction in the presence of stable ventricular size

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  • 1 Division of Neurosurgery, Children’s Hospital Los Angeles; and
  • 2 Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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OBJECTIVE

The authors sought to determine the reliability of a radiopharmaceutical (RP) shunt flow study for the detection of a CSF-diverting shunt malfunction in the presence of stable ventricular size.

METHODS

After the authors obtained IRB approval, all CSF RP shunt flow studies done between January 1, 2014, and January 1, 2019, in pediatric patients at Children’s Hospital Los Angeles were identified. Included in the study were only those patients in whom an MRI or CT scan was done during the hospital admission for shunt malfunction and showed no increase in ventricular size compared with the most recent prior MRI or CT scan when the patient was asymptomatic. Data recorded for analysis were patient age and sex, etiology of the hydrocephalus, shunt distal site, nonprogrammable versus programmable valve, operative findings if the shunt was revised, and follow-up findings for a minimum of 90 days after admission. The RP shunt flow study consisted of tapping the reservoir and injecting technetium-99m DTPA according to a set protocol.

RESULTS

The authors identified 146 RP flow studies performed in 119 patients meeting the above criteria. Four of the 146 RP studies (3%) were nondiagnostic secondary to technical failure and were excluded from statistical analysis. Of the 112 normal flow studies, operative intervention was not undertaken in 102 (91%). The 10 (9%) remaining normal studies were performed in patients who underwent operative intervention, in which 8 patients had a proximal obstruction, 1 had a distal obstruction, and 1 patient had no obstruction. Of the 30 patients with abnormal flow studies, symptoms of shunt malfunction subsided in 9 (30%) patients and these patients did not undergo operative intervention. Of the 21 (70%) operated patients, obstruction was proximal in 9 patients and distal in 5, and for 7 patients the shunt tubing was either fractured or disconnected. Regression analysis indicated a significant association between the flow study interpretation and the odds for shunt revision (OR 27, 95% CI 10–75, p < 0.0001). No other clinical variables were significant. The sensitivity of a shunt flow study alone for detection of shunt malfunction in cases with stable ventricular size was the same as a shunt flow study plus an MRI or CT (70% vs 70%), but performing a shunt flow in addition to MRI or CT did increase the specificity from 92% to 100% and the accuracy from 87% to 94%.

CONCLUSIONS

RP shunt flow studies were of definite value in deciding whether to operatively intervene in patients with symptoms of shunt malfunction in whom no change in ventricular size was detected on current MRI or CT scans compared to scans obtained when the patients were asymptomatic.

ABBREVIATIONS NLR = negative likelihood ratio; NPV = negative predictive value; PLR = positive likelihood ratio; PPV = positive predictive value; RP = radiopharmaceutical.

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Contributor Notes

Correspondence J. Gordon McComb: Children’s Hospital Los Angeles, CA. gmccomb@chla.usc.edu.

INCLUDE WHEN CITING Published online July 17, 2020; DOI: 10.3171/2020.4.PEDS2020.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Bondurant CP, Jimenez DF. Epidemiology of cerebrospinal fluid shunting. Pediatr Neurosurg. 1995;23(5):254259.

  • 2

    Guertin SR. Cerebrospinal fluid shunts. Evaluation, complications, and crisis management. Pediatr Clin North Am. 1987;34(1):203217.

  • 3

    Iskandar BJ, Sansone JM, Medow J, Rowley HA. The use of quick-brain magnetic resonance imaging in the evaluation of shunt-treated hydrocephalus. J Neurosurg. 2004;101(2)(suppl):147151.

    • Search Google Scholar
    • Export Citation
  • 4

    Kim TYSG, Stewart G, Voth M, Signs and symptoms of cerebrospinal fluid shunt malfunction in the pediatric emergency department. Pediatr Emerg Care. 2006;22(1):2834.

    • Search Google Scholar
    • Export Citation
  • 5

    Li V, Dias MS. The results of a practice survey on the management of patients with shunted hydrocephalus. Pediatr Neurosurg. 1999;30(6):288295.

    • Search Google Scholar
    • Export Citation
  • 6

    Mater A, Shroff M, Al-Farsi S, Test characteristics of neuroimaging in the emergency department evaluation of children for cerebrospinal fluid shunt malfunction. CJEM. 2008;10(2):131135.

    • Search Google Scholar
    • Export Citation
  • 7

    O’Neill BR, Pruthi S, Bains H, Rapid sequence magnetic resonance imaging in the assessment of children with hydrocephalus. World Neurosurg. 2013;80(6):e307e312.

    • Search Google Scholar
    • Export Citation
  • 8

    Pitetti R. Emergency department evaluation of ventricular shunt malfunction: is the shunt series really necessary? Pediatr Emerg Care. 2007;23(3):137141.

    • Search Google Scholar
    • Export Citation
  • 9

    Di Rocco C, Marchese E, Velardi F. A survey of the first complication of newly implanted CSF shunt devices for the treatment of nontumoral hydrocephalus. Cooperative survey of the 1991-1992 Education Committee of the ISPN. Childs Nerv Syst. 1994;10(5):321327.

    • Search Google Scholar
    • Export Citation
  • 10

    Spiegelman L, Asija R, Da Silva SL, What is the risk of infecting a cerebrospinal fluid-diverting shunt with percutaneous tapping? J Neurosurg Pediatr. 2014;14(4):336339.

    • Search Google Scholar
    • Export Citation
  • 11

    Iskandar BJ, McLaughlin C, Mapstone TB, Pitfalls in the diagnosis of ventricular shunt dysfunction: radiology reports and ventricular size. Pediatrics. 1998;101(6):10311036.

    • Search Google Scholar
    • Export Citation
  • 12

    Lehnert BE, Rahbar H, Relyea-Chew A, Detection of ventricular shunt malfunction in the ED: relative utility of radiography, CT, and nuclear imaging. Emerg Radiol. 2011;18(4):299305.

    • Search Google Scholar
    • Export Citation
  • 13

    Vassilyadi M, Tataryn ZL, Alkherayf F, The necessity of shunt series. J Neurosurg Pediatr. 2010;6(5):468473.

  • 14

    Zorc JJ, Krugman SD, Ogborn J, Benson J. Radiographic evaluation for suspected cerebrospinal fluid shunt obstruction. Pediatr Emerg Care. 2002;18(5):337340.

    • Search Google Scholar
    • Export Citation
  • 15

    Boyle TP, Paldino MJ, Kimia AA, Comparison of rapid cranial MRI to CT for ventricular shunt malfunction. Pediatrics. 2014;134(1):e47e54.

    • Search Google Scholar
    • Export Citation
  • 16

    Engel M, Carmel PW, Chutorian AM. Increased intraventricular pressure without ventriculomegaly in children with shunts: “normal volume” hydrocephalus. Neurosurgery. 1979;5(5):549552.

    • Search Google Scholar
    • Export Citation
  • 17

    Garton HJ, Kestle JR, Drake JM. Predicting shunt failure on the basis of clinical symptoms and signs in children. J Neurosurg. 2001;94(2):202210.

    • Search Google Scholar
    • Export Citation
  • 18

    McNatt SA, Kim A, Hohuan D, Pediatric shunt malfunction without ventricular dilatation. Pediatr Neurosurg. 2008;44(2):128132.

  • 19

    O’Brien DF, Taylor M, Park TS, Ojemann JG. A critical analysis of ‘normal’ radionucleotide shuntograms in patients subsequently requiring surgery. Childs Nerv Syst. 2003;19(5–6):337341.

    • Search Google Scholar
    • Export Citation
  • 20

    Ouellette D, Lynch T, Bruder E, Additive value of nuclear medicine shuntograms to computed tomography for suspected cerebrospinal fluid shunt obstruction in the pediatric emergency department. Pediatr Emerg Care. 2009;25(12):827830.

    • Search Google Scholar
    • Export Citation
  • 21

    Thompson EM, Wagner K, Kronfeld K, Selden NR. Using a 2-variable method in radionuclide shuntography to predict shunt patency. J Neurosurg. 2014;121(6):15041507.

    • Search Google Scholar
    • Export Citation
  • 22

    Vernet O, Farmer JP, Lambert R, Montes JL. Radionuclide shuntogram: adjunct to manage hydrocephalic patients. J Nucl Med. 1996;37(3):406410.

    • Search Google Scholar
    • Export Citation
  • 23

    Winston KR, Lopez JA, Freeman J. CSF shunt failure with stable normal ventricular size. Pediatr Neurosurg. 2006;42(3):151155.

  • 24

    May CH, Aurisch R, Kornrumpf D, Vogel S. Evaluation of shunt function in hydrocephalic patients with the radionuclide 99mTc-pertechnetate. Childs Nerv Syst. 1999;15(5):239245.

    • Search Google Scholar
    • Export Citation
  • 25

    Shuaib W, Johnson JO, Pande V, Ventriculoperitoneal shunt malfunction: cumulative effect of cost, radiation, and turnaround time on the patient and the health care system. AJR Am J Roentgenol. 2014;202(1):1317.

    • Search Google Scholar
    • Export Citation
  • 26

    Jonson R, Ahlberg J, Mattsson S, Patient exposure when using 99Tcm-DTPA for evaluation of cerebrospinal fluid shunt patency. Acta Radiol. 1988;29(3):378380.

    • Search Google Scholar
    • Export Citation
  • 27

    McComb JG. Commentary: converting pediatric patients and young adults from a shunt to a third ventriculostomy: a multicenter evaluation. Neurosurgery. Published online November 26, 2019. doi:10.1093/neuros/nyz483

    • Search Google Scholar
    • Export Citation

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