Comparative durability and costs analysis of ventricular shunts

Restricted access


Ventricular shunt (VS) durability has been well studied in the pediatric population and in patients with normal pressure hydrocephalus; however, further evaluation in a more heterogeneous adult population is needed. This study aims to evaluate the effect of diagnosis and valve type—fixed versus programmable—on shunt durability and cost for placement of shunts in adult patients.


The authors retrospectively reviewed the medical records of all patients who underwent implantation of a VS for hydrocephalus at their institution over a 3-year period between August 2013 and October 2016 with a minimum postoperative follow-up of 6 months. The primary outcome was shunt revision, which was defined as reoperation for any indication after the initial procedure. Supply costs, shunt durability, and hydrocephalus etiologies were compared between fixed and programmable valves.


A total of 417 patients underwent shunt placement during the index time frame, consisting of 62 fixed shunts (15%) and 355 programmable shunts (85%). The mean follow-up was 30 ± 12 (SD) months. The shunt revision rate was 22% for programmable pressure valves and 21% for fixed pressure valves (HR 1.1 [95% CI 0.6–1.8]). Shunt complications, such as valve failure, infection, and overdrainage, occurred with similar frequency across valve types. Kaplan-Meier survival curve analysis showed no difference in durability between fixed (mean 39 months) and programmable (mean 40 months) shunts (p = 0.980, log-rank test). The median shunt supply cost per index case and accounting for subsequent revisions was $3438 (interquartile range $2938–$3876) and $1504 (interquartile range $753–$1584) for programmable and fixed shunts, respectively (p < 0.001, Wilcoxon rank-sum test). Of all hydrocephalus etiologies, pseudotumor cerebri (HR 1.9 [95% CI 1.2–3.1]) and previous shunt malfunction (HR 1.8 [95% CI 1.2–2.7]) were found to significantly increase the risk of shunt revision. Within each diagnosis, there were no significant differences in revision rates between shunts with a fixed valve and shunts with a programmable valve.


Long-term shunt revision rates are similar for fixed and programmable shunt pressure valves in adult patients. Hydrocephalus etiology may play a significant role in predicting shunt revision, although programmable valves incur higher supply costs regardless of initial diagnosis. Utilization of fixed pressure valves versus programmable pressure valves may reduce supply costs while maintaining similar revision rates. Given the importance of developing cost-effective management protocols, this study highlights the critical need for large-scale prospective observational studies and randomized clinical trials of ventricular shunt valve revisions and additional patient-centered outcomes.

ABBREVIATIONS NPH = normal pressure hydrocephalus; VS = ventricular shunt.

Article Information

Correspondence Robert M. Friedlander: University of Pittsburgh Medical Center, Pittsburgh, PA.

INCLUDE WHEN CITING Published online May 11, 2018; DOI: 10.3171/2017.11.JNS172212.

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

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Flowchart demonstrating prior shunt history, total patient cohort, and primary outcomes including the time range of data collection. Figure is available in color online only.

  • View in gallery

    Probability of shunt survival with time in months as estimated by Kaplan-Meier survival curve analysis for fixed and programmable valve types.



Agarwal NAgarwal PQuerry AMazurkiewicz AWhiteside BMarroquin OC: Reducing surgical infections and implant costs via a novel paradigm of enhanced physician awareness. Neurosurgery [epub ahead of print] 2017


Bergsneider MMiller CVespa PMHu X: Surgical management of adult hydrocephalus. Neurosurgery 62 (Suppl 2):6436602008


Bir SCPatra DPMaiti TKSun HGuthikonda BNotarianni C: Epidemiology of adult-onset hydrocephalus: institutional experience with 2001 patients. Neurosurg Focus 41(3):E52016


Brean AEide PK: Prevalence of probable idiopathic normal pressure hydrocephalus in a Norwegian population. Acta Neurol Scand 118:48532008


Farahmand DHilmarsson HHögfeldt MTisell M: Perioperative risk factors for short term shunt revisions in adult hydrocephalus patients. J Neurol Neurosurg Psychiatry 80:124812532009


Farahmand DSæhle TEide PKTisell MHellström PWikkelsö C: A double-blind randomized trial on the clinical effect of different shunt valve settings in idiopathic normal pressure hydrocephalus. J Neurosurg 124:3593672016


Lemcke JMeier UMüller CFritsch MJKehler ULanger N: Safety and efficacy of gravitational shunt valves in patients with idiopathic normal pressure hydrocephalus: a pragmatic, randomised, open label, multicentre trial (SVASONA). J Neurol Neurosurg Psychiatry 84:8508572013


Li MWang HOuyang YYin MYin X: Efficacy and safety of programmable shunt valves for hydrocephalus: a meta-analysis. Int J Surg 44:1391462017


Lund-Johansen MSvendsen FWester K: Shunt failures and complications in adults as related to shunt type, diagnosis, and the experience of the surgeon. Neurosurgery 35:8398441994


McGirt MJBuck DW IISciubba DWoodworth GFCarson BWeingart J: Adjustable vs set-pressure valves decrease the risk of proximal shunt obstruction in the treatment of pediatric hydrocephalus. Childs Nerv Syst 23:2892952007


Patwardhan RVNanda A: Implanted ventricular shunts in the United States: the billion-dollar-a-year cost of hydrocephalus treatment. Neurosurgery 56:1391452005


Pollack IFAlbright ALAdelson PD: A randomized, controlled study of a programmable shunt valve versus a conventional valve for patients with hydrocephalus. Neurosurgery 45:139914111999


Reddy GKShi RNanda AGuthikonda B: Obstructive hydrocephalus in adult patients: the Louisiana State University Health Sciences Center-Shreveport experience with ventriculoperitoneal shunts. World Neurosurg 76:1761822011 (Erratum in World Neurosurg 78:e1 2012)


Ringel FSchramm JMeyer B: Comparison of programmable shunt valves vs standard valves for communicating hydrocephalus of adults: a retrospective analysis of 407 patients. Surg Neurol 63:36412005


Sotelo JArriada NLópez MA: Ventriculoperitoneal shunt of continuous flow vs valvular shunt for treatment of hydrocephalus in adults. Surg Neurol 63:1972032005


Weiner HLConstantini SCohen HWisoff JH: Current treatment of normal-pressure hydrocephalus: comparison of flow-regulated and differential-pressure shunt valves. Neurosurgery 37:8778841995


Wu YGreen NLWrensch MRZhao SGupta N: Ventriculoperitoneal shunt complications in California: 1990 to 2000. Neurosurgery 61:5575632007


Zemack GRomner B: Do adjustable shunt valves pressure our budget? A retrospective analysis of 541 implanted Codman Hakim programmable valves. Br J Neurosurg 15:2212272001


Ziebell MWetterslev JTisell MGluud CJuhler M: Flow-regulated versus differential pressure-regulated shunt valves for adult patients with normal pressure hydrocephalus. Cochrane Database Syst Rev (5):CD0097062013




All Time Past Year Past 30 Days
Abstract Views 112 112 22
Full Text Views 225 225 12
PDF Downloads 92 92 8
EPUB Downloads 0 0 0


Google Scholar