Investigation of ventriculoperitoneal shunt disconnection for hydrocephalus treatment

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  • 1 College of Medicine, Central Michigan University, Mount Pleasant, Michigan; and
  • 2 School of Medicine,
  • 3 Department of Biomedical Engineering,
  • 4 Department of Neurosurgery, and
  • 5 Department of Chemical Engineering and Material Science, Wayne State University, Detroit, Michigan
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OBJECTIVE

This investigation is aimed at gaining a better understanding of the factors that lead to mechanical failure of shunts used for the treatment of hydrocephalus, including shunt catheter-valve disconnection and shunt catheter fracture.

METHODS

To determine the root cause of mechanical failure, the authors created a benchtop mechanical model to mimic mechanical stressors on a shunt system. To test shunt fracture, cyclical loading on the catheter-valve connection site was tested with the shunt catheter held perpendicular to the valve. Standard methods were used to secure the catheter and valves with Nurolon. These commercial systems were compared to integrated catheters and valves (manufactured as one unit). To test complete separation/disconnection of the shunt catheter and valve, a parallel displacement test was conducted using both Nurolon and silk sutures. Finally, the stiffness of the catheters was assessed. All mechanical investigations were conducted on shunts from two major shunt companies, assigned as either company A or company B.

RESULTS

Cyclical loading experiments found that shunts from company B fractured after a mean of 4936 ± 1725 cycles (95% CI 2990–6890 cycles), while those of company A had not failed after 8000 cycles. The study of parallel displacement indicated complete disconnection of company B’s shunt catheter-valve combination using Nurolon sutures after being stretched an average 32 ± 5.68 mm (95% CI 25.6–38.4 mm), whereas company A’s did not separate using either silk or Nurolon sutures. During the stiffness experiments, the catheters of company B had statistically significantly higher stiffness of 13.23 ± 0.15 N compared to those of company A, with 6.16 ± 0.29 N (p < 0.001).

CONCLUSIONS

Mechanical shunt failure from shunt catheter-valve disconnection or fracture is a significant cause of shunt failure. This study demonstrates, for the first time, a correlation between shunt catheters that are less mechanically stiff and those that are less likely to disconnect from the valve when outstretched and are also less likely to tear when held at an angle from the valve outlet. The authors propose an intervention to the standard of care wherein less stiff catheters are trialed to reduce disconnection.

ABBREVIATIONS ISO = International Organization for Standardization; VP = ventriculoperitoneal.

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Contributor Notes

Correspondence Carolyn A. Harris: Wayne State University, Detroit, MI. caharris@wayne.edu.

INCLUDE WHEN CITING Published online November 13, 2020; DOI: 10.3171/2020.6.PEDS20454.

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

    Isaacs AM, Riva-Cambrin J, Yavin D, Age-specific global epidemiology of hydrocephalus: systematic review, metanalysis and global birth surveillance. PLoS One. 2018;13(10):e0204926.

    • Search Google Scholar
    • Export Citation
  • 2

    Browd SR, Ragel BT, Gottfried ON, Kestle JRW. Failure of cerebrospinal fluid shunts: Part I: Obstruction and mechanical failure. Pediatr Neurol. 2006;34(2):8392.

    • Search Google Scholar
    • Export Citation
  • 3

    Pople IK. Hydrocephalus and shunts: what the neurologist should know. J Neurol Neurosurg Psychiatry. 2002;73(1)(suppl 1):i17i22.

  • 4

    Wang YM, Lin YJ, Chuang MJ, Predictors and outcomes of shunt-dependent hydrocephalus in patients with aneurysmal sub-arachnoid hemorrhage. BMC Surg. 2012;12(3):12.

    • Search Google Scholar
    • Export Citation
  • 5

    Drake JM. The surgical management of pediatric hydrocephalus. Neurosurgery. 2008;62(2)(suppl 2):633642.

  • 6

    Patwardhan RV, Nanda A. Implanted ventricular shunts in the United States: the billion-dollar-a-year cost of hydrocephalus treatment. Neurosurgery. 2005;56(1):139145.

    • Search Google Scholar
    • Export Citation
  • 7

    Del Bigio MR. Epidemiology and direct economic impact of hydrocephalus: a community based study. Can J Neurol Sci. 1998;25(2):123126.

    • Search Google Scholar
    • Export Citation
  • 8

    Simon TD, Riva-Cambrin J, Srivastava R, Hospital care for children with hydrocephalus in the United States: utilization, charges, comorbidities, and deaths. J Neurosurg Pediatr. 2008;1(2):131137.

    • Search Google Scholar
    • Export Citation
  • 9

    Black C, Resau J, West R, Are we implanting catheters that facilitate shunt failure? Fluids Barriers CNS. 2009;6:S42.

  • 10

    Hanak BW, Ross EF, Harris CA, Toward a better understanding of the cellular basis for cerebrospinal fluid shunt obstruction: report on the construction of a bank of explanted hydrocephalus devices. J Neurosurg Pediatr. 2016;18(2):213223.

    • Search Google Scholar
    • Export Citation
  • 11

    Hanak BW, Bonow RH, Harris CA, Browd SR. Cerebrospinal fluid shunting complications in children. Pediatr Neurosurg. 2017;52(6):381400.

    • Search Google Scholar
    • Export Citation
  • 12

    Drake JM, Kestle JR, Tuli S. CSF shunts 50 years on—past, present and future. Childs Nerv Syst. 2000;16(10-11):800804.

  • 13

    Harris CA, Resau JH, Hudson EA, Mechanical contributions to astrocyte adhesion using a novel in vitro model of catheter obstruction. Exp Neurol. 2010;222(2):204210.

    • Search Google Scholar
    • Export Citation
  • 14

    Sainte-Rose C, Piatt JH, Renier D, Mechanical complications in shunts. Pediatr Neurosurg. 1991-1992;17(1):29.

  • 15

    Silver E, Wu R, Grady J, Song L. Knot security—How is it affected by suture technique, material, size, and number of throws? J Oral Maxillofac Surg. 2016;74(7):13041312.

    • Search Google Scholar
    • Export Citation
  • 16

    Johansson I, Karlsson M, Shukla VK, Water transport activity of the plasma membrane aquaporin PM28A is regulated by phosphorylation. Plant Cell. 1998;10(3):451459.

    • Search Google Scholar
    • Export Citation
  • 17

    Aldrich EF, Harmann P. Disconnection as a cause of ventriculoperitoneal shunt malfunction in multicomponent shunt systems. Pediatr Neurosurg. 1990-1991;16(6):309312.

    • Search Google Scholar
    • Export Citation
  • 18

    Langmoen IA, Lundar T, Vatne K, Occurrence and management of fractured peripheral catheters in CSF shunts. Childs Nerv Syst. 1992;8(4):222225.

    • Search Google Scholar
    • Export Citation
  • 19

    Raimondi AJ, Robinson JS, Kuwawura K. Complications of ventriculo-peritoneal shunting and a critical comparison of the three-piece and one-piece systems. Childs Brain. 1977;3(6):321342.

    • Search Google Scholar
    • Export Citation
  • 20

    International Organization for Standardization. ISO 7197:2006 Neurosurgical implants—Sterile, single-use hydrocephalus shunts and components. Accessed August 3, 2020. https://www.iso.org/standard/38403.html

    • Search Google Scholar
    • Export Citation
  • 21

    FDA. ASTM F647-94 (Reapproved 2014) Standard practice for evaluating and specifying implantable shunt assemblies for neurosurgical application. 08/14/2015. Accessed August 3, 2020. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfStandards/detail.cfm?standard__identification_no=33268

    • Search Google Scholar
    • Export Citation

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