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Jeffrey J. Quezada and J. Gordon McComb

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.

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Eisha A. Christian, Jeffrey J. Quezada, Edward F. Melamed, Carolyn Lai, and J. Gordon McComb

OBJECTIVE

The authors sought to determine the outcome of using the pleural space as the terminus for ventricular CSF-diverting shunts in a pediatric population.

METHODS

All ventriculopleural (VPl) shunt insertions or revisions done between 1978 and 2018 in patients at Children’s Hospital Los Angeles were identified. Data recorded for analysis were age, sex, weight, etiology of hydrocephalus, previous shunt history, reason for VPl shunt insertion or conversion from a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt, valve type, nature of malfunction, presence of shunt infection or pleural effusion, and conversion to a different distal site.

RESULTS

A total of 170 patients (mean age 14 ± 4 years) with a VPl shunt who were followed up for a mean of 57 ± 53 months were identified. The reasons for conversion to a VPl shunt for 167 patients were previous shunt infection in 57 (34%), multiple abdominal procedures in 44 (26%), inadequate absorption of CSF in 34 (20%), abdominal pseudocyst in 25 (15%), and obesity in 7 (4%). No VPl revisions were required in 97 (57%) patients. Of the 73 (43%) patients who did require revision, the most common reason was proximal obstruction in 32 (44%). The next most frequent complication was pleural effusion in 22 (30%) and included 3 patients with shunt infection. All 22 patients with a clinically significant pleural effusion required changing the distal end of the shunt from the pleural space. Pleural effusion was more likely to occur in VPl shunts without an antisiphon valve. Of the 29 children < 10 years old, 7 (24%) developed a pleural effusion requiring a revision of the distal catheter to outside the pleural space compared with 15 (11%) who were older (p = 0.049). There were 14 shunt infections with a rate of 4.2% per procedure and 8.2% per patient.

CONCLUSIONS

VPl shunts in children younger than 10 years of age have a significantly higher rate of symptomatic pleural effusion, requiring revision of the shunt’s terminus to a different location. VPl shunt complication rates are similar to those of VP shunts. The technical difficulty of inserting a VPl shunt is comparable to that of a VP shunt. In a patient older than 10 years, all else being equal, the authors recommend that the distal end of a shunt be placed into the pleural space rather than the right atrium if the peritoneal cavity is not suitable.