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William E. Whitehead, Jay Riva-Cambrin, John C. Wellons III, Abhaya V. Kulkarni, David D. Limbrick Jr., Vanessa L. Wall, Curtis J. Rozzelle, Todd C. Hankinson, Patrick J. McDonald, Mark D. Krieger, Ian F. Pollack, Mandeep S. Tamber, Jonathan Pindrik, Jason S. Hauptman, Robert P. Naftel, Chevis N. Shannon, Jason Chu, Eric M. Jackson, Samuel R. Browd, Tamara D. Simon, Richard Holubkov, Ron W. Reeder, Hailey Jensen, Jenna E. Koschnitzky, Paul Gross, James M. Drake, and John R. W. Kestle

, patients were screened for shunt failure and complications. We reviewed all postoperative imaging studies. All patients were followed until the last included patient at each center had a minimum of 18 months of follow-up. All staff pediatric neurosurgeons at participating centers could participate in the trial. For every patient randomized, surgeons were required to record their shunt entry site preference before receiving the randomized entry site. Study Design and Objectives This was a parallel-design randomized controlled trial. The primary objective of the

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William E. Whitehead, Jay Riva-Cambrin, Abhaya V. Kulkarni, John C. Wellons III, Curtis J. Rozzelle, Mandeep S. Tamber, David D. Limbrick Jr., Samuel R. Browd, Robert P. Naftel, Chevis N. Shannon, Tamara D. Simon, Richard Holubkov, Anna Illner, D. Douglas Cochrane, James M. Drake, Thomas G. Luerssen, W. Jerry Oakes, and John R. W. Kestle

studies. Based on this study, a randomized controlled trial has been planned and is currently recruiting patients within the HCRN (The CSF Shunt Entry Site Trial, clinicaltrials.gov : NCT02425761). A well-designed randomized controlled trial limits the effect of confounders and bias; it is the best methodology for comparing 2 treatments. The results of such a trial are necessary before treatment recommendations can be made regarding the best shunt entry site. Conclusions Using a large cohort of pediatric patients undergoing first-time shunt insertion, we failed

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William E. Whitehead, Jay Riva-Cambrin, John C. Wellons III, Abhaya V. Kulkarni, Samuel Browd, David Limbrick, Curtis Rozzelle, Mandeep S. Tamber, Tamara D. Simon, Chevis N. Shannon, Richard Holubkov, W. Jerry Oakes, Thomas G. Luerssen, Marion L. Walker, James M. Drake, and John R. W. Kestle

collected during the study were reviewed and the following variables were analyzed for their possible association with catheter movement and inaccurate catheter location: experience of attending surgeon (< 10 years vs ≥ 10 years); number of ultrasound sound procedures performed by the attending surgeon prior to the study (< 50 vs ≥ 50 procedures); patient age (< 6 months vs ≥ 6 months); frontal occipital ratio (< 0.55 vs ≥ 0.55) 4 ; cortical mantle thickness (< 1 cm vs ≥ 1 cm); shunt entry site (anterior vs posterior); shunt equipment at entry site (no right angle device

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Prospective multicenter studies in pediatric hydrocephalus

JNSPG 75th Anniversary Invited Review Article

John R. W. Kestle and Jay Riva-Cambrin

appears that studies to reduce shunt failure are feasible and meaningful and deserve more attention. Studies of Surgical Technique Two prospective multicenter RCTs have studied specific intraoperative techniques for shunt insertion. A trial comparing entry sites for the ventricular catheter is underway (Whitehead W: Rationale and methodology of the CSF Shunt Entry Site Trial, presented at the 7th Annual Meeting of the International Society for Hydrocephalus and Cerebrospinal Fluid Disorders, Banff, Alberta, Canada, September 19–21, 2015). Children receiving their first

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Michael R. Levitt, Brent R. O'Neill, Gisele E. Ishak, Paritosh C. Khanna, Nancy R. Temkin, Richard G. Ellenbogen, Jeffrey G. Ojemann, and Samuel R. Browd

parietal or occipital shunts, although the exact target used in the image guidance group was not recorded. Several groups have studied the choice of catheter entry location (frontal, parietal, or occipital) on shunt function and survival, and the data are conflicting. The first major study of shunt entry site and shunt survival 2 found that shunts placed via a frontal bur hole survived significantly longer than parietal shunts. Shortly thereafter, a prospective randomized study 5 of 121 patients undergoing initial shunt insertions compared frontal and parietooccipital