Epidemiology and practice variations of shunt surgery for hydrocephalus: a nationwide registry-based study.

OBJECTIVE: Indications for surgical treatment of hydrocephalus (HC) can vary across centers. The authors sought to investigate the frequencies of surgically treated HC disorders and to study variations in the practice of shunt surgery in Norway, a country with universal and free healthcare. METHODS: This is a nationwide registry-based study using data from the Norwegian Patient Registry. Four neurosurgical centers serve exclusively in 4 defined geographic regions. All patients who underwent shunt surgery in Norway between January 1, 2008, and December 31, 2021, were included and regional differences and time trends were explored. RESULTS: The national annual rate of shunt surgery in the study period was 6.0 per 100,000. A total of 4139 individuals (49.5% male) underwent primary shunt surgeries, and a total of 9262 operations including revision surgeries were performed. There were statistically significant regional differences between the 4 treating centers in Norway in terms of patients' age (median 61 years, range 53-65 years); mean annual rate of primary shunt surgery (5.1-7.6 per 100,000); annual rate of primary shunt surgery in patients of different age groups (0.9-1.2 in 0-17 years, 1.8-2.7 in 18-64 years, and 1.6-3.9 in ≥ 65 years); annual rate of revision surgeries (2.4-5.7 per 100,000); annual rate of primary surgery for communicating HC (0.7-2.0 per 100,000); annual rate of primary surgery for normal pressure HC (0.5-1.8 per 100,000); and annual rate of primary surgery for HC associated with cerebrovascular disease (0.5-2.0 per 100,000). There was significant variation in overall shunt surgeries during the study period (p = 0.026), and there was an overall decrease in revision surgeries over time (p < 0.001). There appears to be a homogenization of revision surgeries over time. CONCLUSIONS: There are significant and large practice variations in the surgical management of HC in Norway. There are significant differences between regions, particularly in terms of rates of shunt surgery for some diagnoses (communicating HC, normal pressure HC, and HC associated with cerebrovascular disease) as well as revision rates.

Shunt complications and revisions in children: A retrospective single institution study.

INTRODUCTION: Shunt surgery in children is associated with high revision and complication rates. We investigated revision rates and postoperative complications to specify current challenges associated with pediatric shunt surgery. METHODS: All patients aged < 18 years admitted to St. Olavs University Hospital, Norway, from January 2008 through December 2017, who underwent primary shunt insertions, were reviewed. Follow-up ranged from 1 to 10 years. Ventriculoperitoneal, cystoperitoneal, and ventriculoatrial shunts were included. All subsequent shunt revisions and 30-day postoperative complication rates were registered. RESULTS: 81 patients underwent 206 surgeries in the study period. 47 patients (58%) required minimum one revision during follow-up. In 14 (29.8%), the first revision was due to the misplacement of hardware. Proximal occlusion was the most common cause of revision (30.4%), followed by misplacement (18.5%) and infection (9.6%). Young age and MMC were associated with revision surgery in a univariable analysis, but were not significant in multivariable analyses. Congenital hydrocephalus was associated with infection (p = .028). In approximately 30% of procedures, complications occurred within 30 days postoperatively, the most common being revision surgery. In approximately 5% of the procedures, medical complications occurred. CONCLUSION: Children are prone to high revision and complication rates, and in this study, misplacement of hardware and proximal occlusion were the most common. Complication rates should not be limited to revision rates only, as 30-day complication rates indicate a significant rate of other complications as well. Multi-targeted approaches, perhaps focusing on measures to reduce misplacement, may be key to reducing revision rates.

Revision and complication rates in adult shunt surgery: a single-institution study.

BACKGROUND: CSF diversion with shunt placement is frequently associated with need for later revisions as well as surgical complications. We sought to review revision and complication rates following ventriculoperitoneal, ventriculoatrial and cystoperitoneal shunt placement in adult patients, and to identify potential risk factors for revision surgery and postoperative complications. METHOD: Included patients were adults (≥ 18 years) who underwent primary shunt insertion at St. Olavs Hospital in Trondheim, Norway, from 2008 through 2017. The electronic medical records and diagnostic imaging from all hospitals in our catchment area were retrospectively reviewed. Follow-up ranged from 1 to 11 years. Complications were graded according to the Landriel Ibañez classification system. RESULTS: Of the 227 patients included, 47 patients (20.7%) required revision surgery during the follow-up. In total, 90 revision surgeries were performed during follow-up. The most common cause for the first revision was infection (5.7%) and for all revisions proximal occlusion (30.0%). A total of 103 patients (45.4%) experienced ≥ 1 complication(s). Mild to moderate complications (grade I and II) were detected in 35.0% of all procedures. Severe or fatal complications (grade III and IV) were observed in 8.2% of all procedures. Urinary tract infections and pneumonia were common postoperatively (13.9% and 7.3%, respectively), and the most common IIb complication was shunt misplacement (proximally or distally). Two out of fourteen deaths within 30 days were directly associated with surgery. We did not find that aetiology/indication, age or gender influenced the occurrence of revision surgery or a grade III or IV complication. CONCLUSIONS: Shunt surgery continues to be a challenge both in terms of revision rates and procedure-related complications. However, the prediction of patients at risk remains difficult. A multidimensional focus is probably needed to reduce risks.

Accuracy and complication rates of external ventricular drain placement with twist drill and bolt system versus standard trephine and tunnelation: a retrospective population-based study.

BACKGROUND: An external ventricular drain (EVD) is typically indicated in the presence of hydrocephalus and increased intracranial pressure (ICP). Procedural challenges have prompted the development of different methods to improve accuracy, safety, and logistics. OBJECTIVES: EVD placement and complications rates were compared using two surgical techniques; the standard method (using a 14-mm trephine burrhole with the EVD tunnelated through the skin) was compared to a less invasive method (EVD placed through a 2.7-3.3-mm twist drill burrhole and fixed to the bone with a bolt system). METHODS: Retrospective observational study in a single-centre setting between 2008 and 2018. EVD placement was assessed using the Kakarla scoring system. We registered postoperative complications, surgery duration and number of attempts to place the EVD. RESULTS: Two hundred seventy-two patients received an EVD (61 bolt EVDs, 211 standard EVDs) in the study period. Significant differences between the bolt system and the standard method were observed in terms of revision surgeries (8.2% vs. 21.5%, p = 0.020), surgery duration (mean 16.5 vs. 28.8 min, 95% CI 7.64, 16.8, p < 0.001) and number of attempts to successfully place the first EVD (mean 1.72 ± 1.2 vs. 1.32 ± 0.8, p = 0.017). There were no differences in accuracy of placement or complication rates. CONCLUSIONS: The two methods show similar accuracy and postoperative complication rates. Observed differences in both need for revisions and surgery duration favoured the bolt group. Slightly, more attempts were needed to place the initial EVD in the bolt group, perhaps reflecting lower flexibility for angle correction with a twist drill approach.

Direct transport versus interhospital transfer of patients with severe head injury in Norway.

OBJECTIVE: This study compares injury severity and outcome of patients with severe head injury admitted directly to a neurosurgical department with those initially transferred to a local hospital. METHODS: A retrospective analysis of all patients with severe head injury admitted to the Department of Neurosurgery at St Olav University Hospital, Norway, was carried out from 1998 throughout 2002. RESULTS: The study included 146 patients with a median age of 34 (1-88) years. Patients transported directly (57%) had lower field Glasgow Coma Scale (fGCS) [5.5 (3-15) vs. 7 (3-15), P=0.002], higher Injury Severity Score [31.8 (9-75) vs. 27.0 (9-75), P=0.023], higher mortality rates (31 vs. 15%, P=0.042) and reached the neurosurgical department earlier [1.8 (0.3-15.8) vs. 5.5h (0.8-23.0), P<0.001] than those undergoing transfer to a local hospital. Significantly more patients in the direct admission group with a fGCS