Predicting shunt failure on the basis of clinical symptoms and signs in children

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Object. In evaluating pediatric patients for shunt malfunction, predictive values for symptoms and signs are important in deciding which patients should undergo an imaging study, whereas determining clinical findings that correlate with a low probability of shunt failure could simplify management.

Methods. Data obtained during the recently completed Pediatric Shunt Design Trial (PSDT) were analyzed. Predictive values were calculated for symptoms and signs of shunt failure. To refine predictive capability, a shunt score based on a cluster of signs and symptoms was derived and validated using multivariate methods.

Four hundred thirty-one patient encounters after recent shunt insertions were analyzed. For encounters that took place within 5 months after shunt insertion (early encounters), predictive values for symptoms and signs included the following: nausea and vomiting (positive predictive value [PPV] 79%, likelihood ratio [LR] 10.4), irritability (PPV 78%, LR 9.8), decreased level of consciousness (LOC) (PPV 100%), erythema (PPV 100%), and bulging fontanelle (PPV 92%, LR 33.1). Between 9 months and 2 years after shunt insertion (late encounters), only loss of developmental milestones (PPV 83%, LR 36.7) and decreased LOC (PPV 100%) were strongly associated with shunt failure. However, the absence of a symptom or sign still left a 15 to 29% (early encounter group) or 9 to 13% (late encounter group) chance of shunt failure. Using the shunt score developed for early encounters, which sums from 1 to 3 points according to the specific symptoms or signs present, patients with scores of 0, 1, 2, and 3 or greater had shunt failure rates of 4%, 50%, 75%, and 100%, respectively. Using the shunt score derived from late encounters, patients with scores of 0, 1, and 2 or greater had shunt failure rates of 8%, 38%, and 100%, respectively.

Conclusions. In children, certain symptoms and signs that occur during the first several months following shunt insertion are strongly associated with shunt failure; however, the individual absence of these symptoms and signs offers the clinician only a limited ability to rule out a shunt malfunction. Combining them in a weighted scoring system improves the ability to predict shunt failure based on clinical findings.

Article Information

Address reprint requests to: Hugh J. L. Garton, M.D., M.H.Sc., Section of Neurosurgery, Department of Surgery, University of Michigan Medical Center, 2128 Taubman HSC, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109. email: hgarton@umich.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Graphs demonstrating ROC curves for scoring systems. Comparisons between the derivation and validation sets are shown for both early and late encounter groups.

References

  • 1.

    Ashkenazi EUmansky FConstantini Set al: Fever as the initial sign of malfunction in non infected ventriculoperitoneal shunts. Acta Neurochir 114:1311341992Ashkenazi E Umansky F Constantini S et al: Fever as the initial sign of malfunction in non infected ventriculoperitoneal shunts. Acta Neurochir 114:131–134 1992

    • Search Google Scholar
    • Export Citation
  • 2.

    Barquet NDomingo PCaylà JAet al: Prognostic factors in meningococcal disease. Development of a bedside predictive model and scoring system. JAMA 278:4914961997Barquet N Domingo P Caylà JA et al: Prognostic factors in meningococcal disease. Development of a bedside predictive model and scoring system. JAMA 278:491–496 1997

    • Search Google Scholar
    • Export Citation
  • 3.

    Benzel ECMirfakhraee MHadden TA: Evaluation of CSF shunt function: value of functional examination with contrast material. AJNR 12:1431471991Benzel EC Mirfakhraee M Hadden TA: Evaluation of CSF shunt function: value of functional examination with contrast material. AJNR 12:143–147 1991

    • Search Google Scholar
    • Export Citation
  • 4.

    Drake JMKestle J: Rationale and methodology of the multicenter pediatric cerebrospinal fluid shunt design trial. Pediatric Hydrocephalus Treatment Evaluation Group. Childs Nerv Syst 12:4344471996Drake JM Kestle J: Rationale and methodology of the multicenter pediatric cerebrospinal fluid shunt design trial. Pediatric Hydrocephalus Treatment Evaluation Group. Childs Nerv Syst 12:434–447 1996

    • Search Google Scholar
    • Export Citation
  • 5.

    Drake JMKestle JRWMilner Ret al: Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. Neurosurgery 43:2943051998Drake JM Kestle JRW Milner R et al: Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. Neurosurgery 43:294–305 1998

    • Search Google Scholar
    • Export Citation
  • 6.

    Faillace WJCanady AI: Cerebrospinal fluid shunt malfunction signaled by new or recurrent seizures. Childs Nerv Syst 6:37401990Faillace WJ Canady AI: Cerebrospinal fluid shunt malfunction signaled by new or recurrent seizures. Childs Nerv Syst 6:37–40 1990

    • Search Google Scholar
    • Export Citation
  • 7.

    Fouyas IPCasey ATHThompson Det al: Use of intracranial pressure monitoring in the management of childhood hydrocephalus and shunt-related problems. Neurosurgery 38:7267321996Fouyas IP Casey ATH Thompson D et al: Use of intracranial pressure monitoring in the management of childhood hydrocephalus and shunt-related problems. Neurosurgery 38:726–732 1996

    • Search Google Scholar
    • Export Citation
  • 8.

    Hack CHEnrile BGDonat JFet al: Seizures in relation to shunt dysfunction in children with meningomyelocele. J Pediatr 116:57601990Hack CH Enrile BG Donat JF et al: Seizures in relation to shunt dysfunction in children with meningomyelocele. J Pediatr 116:57–60 1990

    • Search Google Scholar
    • Export Citation
  • 9.

    Jamjoom AHBWilson PJE: Misleading clinical syndromes of CSF shunt malfunction. Br J Neurosurg 2:3913941988Jamjoom AHB Wilson PJE: Misleading clinical syndromes of CSF shunt malfunction. Br J Neurosurg 2:391–394 1988

    • Search Google Scholar
    • Export Citation
  • 10.

    Johnson DLConry JO'Donnell R: Epileptic seizure as a sign of cerebrospinal fluid shunt malfunction. Pediatr Neurosurg 24:2232281996Johnson DL Conry J O'Donnell R: Epileptic seizure as a sign of cerebrospinal fluid shunt malfunction. Pediatr Neurosurg 24:223–228 1996

    • Search Google Scholar
    • Export Citation
  • 11.

    Kast JDuong DNowzari Fet al: Time-related patterns of ventricular shunt failure. Childs Nerv Syst 10:5245281994Kast J Duong D Nowzari F et al: Time-related patterns of ventricular shunt failure. Childs Nerv Syst 10:524–528 1994

    • Search Google Scholar
    • Export Citation
  • 12.

    Kirkpatrick MEngleman HMinns RA: Symptoms and signs of progressive hydrocephalus. Arch Dis Child 64:1241281989Kirkpatrick M Engleman H Minns RA: Symptoms and signs of progressive hydrocephalus. Arch Dis Child 64:124–128 1989

    • Search Google Scholar
    • Export Citation
  • 13.

    Mirfakhraee MBenzel ECCrofford MJet al: Metrizamide shuntography for evaluation of shunt malfunction in hydrocephalus. AJNR 6:8158221985Mirfakhraee M Benzel EC Crofford MJ et al: Metrizamide shuntography for evaluation of shunt malfunction in hydrocephalus. AJNR 6:815–822 1985

    • Search Google Scholar
    • Export Citation
  • 14.

    Morgan MKJohnston IHSpittaler PJ: A ventricular infusion technique for the evaluation of treated and untreated hydrocephalus. Neurosurgery 29:8328361991Morgan MK Johnston IH Spittaler PJ: A ventricular infusion technique for the evaluation of treated and untreated hydrocephalus. Neurosurgery 29:832–836 1991

    • Search Google Scholar
    • Export Citation
  • 15.

    Nelson LMBloch DALongstreth WT Jret al: Recursive partitioning for the identification of disease risk subgroups: a case-control study of subarachnoid hemorrhage. J Clin Epidemiol 51:1992091998Nelson LM Bloch DA Longstreth WT Jr et al: Recursive partitioning for the identification of disease risk subgroups: a case-control study of subarachnoid hemorrhage. J Clin Epidemiol 51:199–209 1998

    • Search Google Scholar
    • Export Citation
  • 16.

    Noetzel MJBaker RP: Shunt fluid examination: risks and benefits in the evaluation of shunt malfunction and infection. J Neurosurg 61:3283321984Noetzel MJ Baker RP: Shunt fluid examination: risks and benefits in the evaluation of shunt malfunction and infection. J Neurosurg 61:328–332 1984

    • Search Google Scholar
    • Export Citation
  • 17.

    O'Hayon BBDrake JMOssip MGet al: Frontal and occipital horn ratio: a linear estimate of ventricular size for multiple imaging modalities in pediatric hydrocephalus. Pediatr Neurosurg 29:2452491998O'Hayon BB Drake JM Ossip MG et al: Frontal and occipital horn ratio: a linear estimate of ventricular size for multiple imaging modalities in pediatric hydrocephalus. Pediatr Neurosurg 29:245–249 1998

    • Search Google Scholar
    • Export Citation
  • 18.

    Piatt JH Jr: Cerebrospinal fluid shunt failure: late is different from early. J Neurosurg 82:363A1995 (Abstract)Piatt JH Jr: Cerebrospinal fluid shunt failure: late is different from early. J Neurosurg 82:363A 1995 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 19.

    Piatt JH Jr: Physical examination of patients with cerebrospinal fluid shunts: is there useful information in pumping the shunt? Pediatrics 89:4704731992Piatt JH Jr: Physical examination of patients with cerebrospinal fluid shunts: is there useful information in pumping the shunt? Pediatrics 89:470–473 1992

    • Search Google Scholar
    • Export Citation
  • 20.

    Piatt JH Jr: Pumping the shunt revisited. A longitudinal study. Pediatr Neurosurg 25:73771996Piatt JH Jr: Pumping the shunt revisited. A longitudinal study. Pediatr Neurosurg 25:73–77 1996

    • Search Google Scholar
    • Export Citation
  • 21.

    Pople IK: Doppler flow velocities in children with controlled hydrocephalus: reference values for the diagnosis of blocked cerebrospinal fluid shunts. Childs Nerv Syst 8:1241251992Pople IK: Doppler flow velocities in children with controlled hydrocephalus: reference values for the diagnosis of blocked cerebrospinal fluid shunts. Childs Nerv Syst 8:124–125 1992

    • Search Google Scholar
    • Export Citation
  • 22.

    Sackett DHaynes RGuyatt Get al: Clinical Epidemiology: A Basic Science for Clinical Medicineed 2. Boston: Little, Brown and Company1991Sackett D Haynes R Guyatt G et al: Clinical Epidemiology: A Basic Science for Clinical Medicine ed 2. Boston: Little Brown and Company 1991

    • Search Google Scholar
    • Export Citation
  • 23.

    Saukkonen ALSerlo Wvon Wendt L: Epilepsy in hydrocephalic children. Acta Paediatr Scand 79:2122181990Saukkonen AL Serlo W von Wendt L: Epilepsy in hydrocephalic children. Acta Paediatr Scand 79:212–218 1990

    • Search Google Scholar
    • Export Citation
  • 24.

    Sekhar LNMoossy JGuthkelch AN: Malfunctioning ventriculoperitoneal shunts. Clinical and pathological features. J Neurosurg 56:4114161982Sekhar LN Moossy J Guthkelch AN: Malfunctioning ventriculoperitoneal shunts. Clinical and pathological features. J Neurosurg 56:411–416 1982

    • Search Google Scholar
    • Export Citation
  • 25.

    Simel DLSamsa GPMatchar DB: Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol 44:7637701991Simel DL Samsa GP Matchar DB: Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol 44:763–770 1991

    • Search Google Scholar
    • Export Citation
  • 26.

    Sood SKim SHam SDet al: Useful components of the shunt tap test for evaluation of shunt malfunction. Childs Nerv Syst 9:1571621993Sood S Kim S Ham SD et al: Useful components of the shunt tap test for evaluation of shunt malfunction. Childs Nerv Syst 9:157–162 1993

    • Search Google Scholar
    • Export Citation
  • 27.

    Uvebrant PSixt RBjure Jet al: Evaluation of cerebrospinal fluid shunt function in hydrocephalic children using 99mTc-DTPA. Childs Nerv Syst 8:76801992Uvebrant P Sixt R Bjure J et al: Evaluation of cerebrospinal fluid shunt function in hydrocephalic children using 99mTc-DTPA. Childs Nerv Syst 8:76–80 1992

    • Search Google Scholar
    • Export Citation
  • 28.

    Vernet OFarmer JPLambert Ret al: Radionuclide shuntogram: adjunct to manage hydrocephalic patients. J Nucl Med 37:4064101996Vernet O Farmer JP Lambert R et al: Radionuclide shuntogram: adjunct to manage hydrocephalic patients. J Nucl Med 37:406–410 1996

    • Search Google Scholar
    • Export Citation
  • 29.

    Watkins LHayward RAndar Uet al: The diagnosis of blocked cerebrospinal fluid shunts: a prospective study of referral to a paediatric neurosurgical unit. Childs Nerv Syst 10:87901994Watkins L Hayward R Andar U et al: The diagnosis of blocked cerebrospinal fluid shunts: a prospective study of referral to a paediatric neurosurgical unit. Childs Nerv Syst 10:87–90 1994

    • Search Google Scholar
    • Export Citation
  • 30.

    Zar JH: Biostatistical Analysised 3. Upper Saddle River NJ: Prentice Hall1996Zar JH: Biostatistical Analysis ed 3. Upper Saddle River NJ: Prentice Hall 1996

    • Search Google Scholar
    • Export Citation

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