Survival in treated idiopathic normal pressure hydrocephalus.

OBJECTIVE: To describe survival and causes of death in 979 treated iNPH patients from the Swedish Hydrocephalus Quality Registry (SHQR), and to examine the influence of comorbidities, symptom severity and postoperative outcome. METHODS: All 979 patients operated for iNPH 2004-2011 and registered in the SHQR were included. A matched control group of 4890 persons from the general population was selected by Statistics Sweden. Data from the Swedish Cause of Death Registry was obtained for patients and controls. RESULTS: At a median 5.9 (IQR 4.2-8.1) year follow-up, 37% of the iNPH patients and 23% of the controls had died. Mortality was increased in iNPH patients by a hazard ratio of 1.81, 95% CI 1.61-2.04, p < 0.001. More pronounced symptoms in the preoperative ordinal gait scale and the Mini-mental State Examination were the most important independent predictors of mortality along with the prevalence of heart disease. Patients who improved in both the gait scale and in the modified Rankin Scale postoperatively (n = 144) had a similar survival as the general population (p = 0.391). Deaths due to cerebrovascular disease or dementia were more common in iNPH patients, while more controls died because of neoplasms or disorders of the circulatory system. CONCLUSIONS: Mortality in operated iNPH patients is 1.8 times increased compared to the general population, a lower figure than previously reported. The survival of iNPH patients who improve in gait and functional independence is similar to that of the general population, indicating that shunt surgery for iNPH, besides improving symptoms and signs, can normalize survival.

Subdural hematomas in 1846 patients with shunted idiopathic normal pressure hydrocephalus: treatment and long-term survival.

OBJECTIVE Subdural hematoma (SDH) is the most common serious adverse event in patients with shunts. Adjustable shunts are used with increasing frequency and make it possible to noninvasively treat postoperative SDH. The objective of this study was to describe the prevalence and treatment preferences of SDHs, based on fixed or adjustable shunt valves, in a national cohort of patients with shunted idiopathic normal pressure hydrocephalus (iNPH), as well as to evaluate the effect of SDH and treatment on long-term survival. METHODS Patients with iNPH who received a CSF shunt in Sweden from 2004 to 2015 were included in a prospective quality registry (n = 1846) and followed regarding SDH, its treatment, and mortality. The treatment of SDH was categorized into surgery, opening pressure adjustments, or no treatment. RESULTS During the study period, the proportion of adjustable shunts increased from 75% to 95%. Ten percent (n = 184) of the patients developed an SDH. In 103 patients, treatment was solely opening pressure adjustment. Surgical treatment was used in 66 cases (36%), and 15 (8%) received no treatment. In patients with fixed shunt valves, 90% (n = 17) of SDHs were treated surgically compared with 30% (n = 49) in patients with adjustable shunts (p < 0.001). There was no difference in long-term patient survival between the SDH and non-SDH groups or between different treatments. CONCLUSIONS SDH remains a common complication after shunt surgery, but adjustable shunts reduced the need for surgical interventions. SDH and treatment did not significantly affect survival in this patient group, thus the noninvasive treatment offered by adjustable shunts considerably reduces the level of severity for this common adverse event.

Quality of Life in Individuals Surgically Treated for Congenital Hydrocephalus During Infancy: A Single-Institution Experience.

BACKGROUND: Congenital hydrocephalus (CH) is a frequently encountered birth anomaly that can hinder long-term neurologic maturity and social well-being of affected children. This study was undertaken to assess quality of life (QOL) 10-15 years after surgical treatment for primary CH during infancy at a tertiary care hospital in a developing country. METHODS: This retrospective cohort study included individuals who presented to Aga Khan University Hospital, Karachi, Pakistan, between 1995 and 2005 at <1 year old and underwent surgery for primary CH. The Hydrocephalus Outcome Questionnaire was used to assess outcomes with respect to QOL. RESULTS: Of 118 patients, 90 patients participated in the study. Mean age at first admission was 6.2 months. Mean length of follow-up was 5.4 years. Of these, 28 patients had died after surgery. Shunt infection (P = 0.012) and delayed milestones (P = 0.003) were found to be statistically significant factors affecting mortality in the patients who died. The mean overall health score was 0.67 ± 0.30. Age <6 months at the time of first surgery was a poor predictor of overall health on the Hydrocephalus Outcome Questionnaire (P = 0.039). CONCLUSIONS: In our analysis, we assessed the QOL associated with CH. We hope that these results will provide insight for future prospective work with the ultimate goal of improving long-term QOL in children with CH.

Stress-Induced Hyperglycemia After Spontaneous Subarachnoid Hemorrhage and Its Role in Predicting Cerebrospinal Fluid Diversion.

BACKGROUND: Stress-induced hyperglycemia (SIH) after acute cerebrovascular disease is common and is associated with adverse clinical outcomes. The incidence of SIH after spontaneous subarachnoid hemorrhage (SAH) and its role in shunt placement have not been systematically investigated. The present study is designed to investigate the incidence of SIH after spontaneous SAH and its determinants. The role of SIH and premorbid hyperglycemia (using glycated hemoglobin [HbA1c]) in predicting external ventricular drainage (EVD) and ventriculoperitoneal shunt (VPS) placement is also investigated. METHODS: This study defined SIH using the glycemic gap (GG) and admission glucose:HbA1c ratio. The receiver operating characteristic curve determined threshold values for GG and the ratio that best predicted incidence of adverse clinical outcomes, including in-hospital mortality. RESULTS: We defined SIH using thresholds of 26.7 mg/dL for GG and 26 mg/dL for admission glucose:HbA1c ratio. The incidence of SIH was higher in patients with aneurysmal SAH (aSAH) (99/200 [49.5%]) than in those with nonaneurysmal SAH (16/50 [32.0%]; P = 0.03). Among 200 patients with aSAH, diabetics had higher mortality than nondiabetics (10/24 [41.7%] vs. 39/137 [21.2%]; P = 0.045). SIH among nonhydrocephalic aSAH was more likely to have EVD placed than those without (42/64 [65.6%] vs. 38/79 [48.1%]; P = 0.043). Among 143 patients with aSAH without hydrocephalus, EVD was placed more often in those with HbA1c level ≥6.4% (15/19 [78.9%] vs. 65/124 [52.4%]; P = 0.045). Neither SIH nor HbA1c level could predict VPS placement among aSAH survivors. CONCLUSIONS: SIH is common after aSAH. In nonhydrocephalic aSAH, both SIH and premorbid uncontrolled hyperglycemia determine EVD but not VPS placement.

Long-term mortality rates in pediatric hydrocephalus-a retrospective single-center study.

PURPOSE: Very long-term follow-up and outcome are rare for pediatric patients with hydrocephalus and shunt operations. The aim of this study was to determine the long-term mortality rates in these patients. METHODS: Pediatric patients with first shunt operation between 1982 and 1992 were included. For each patient, time and cause of death were determined. Further, patients with first operation from 1982 to 1987 were compared to those first operated from 1988 to 1992. RESULTS: One-hundred thirty-seven patients were included. Etiologies of hydrocephalus were intraventricular hemorrhage (31.4 %), meningomyelocele (25.5 %), postinfectious (11.7 %), congenital (10.2 %), posterior fossa cyst (8.8 %), aqueductal stenosis (8 %), and others (4.4 %). Overall, 53 patients (38.7 %) died. The percentage of patients surviving 1, 2, 10, and 20 years after first operation were 82.6, 73.6, 69.4, and 65.3 %, respectively. In 23 patients, the cause of death was related to shunt treatment: shunt infection was diagnosed in 18 and acute shunt dysfunction in 5 patients. Mortality was considerably higher for patients with their first operation in time period 1982-1987 compared to time period 1988-1992 (51 versus 25 %). The reduction of mortality was mainly due to an increased survival after shunt infection. Eighty-seven patients survived more than 20 years after initial shunt operation. Of those long-term survivors, three (3.4 %) patients died 22-24 years after first operation. CONCLUSION: Mortality in hydrocephalic pediatric patients is high especially in the first postoperative years but is even significant in adult patients with pediatric hydrocephalus. As deaths occur even after 20 years, routine follow-up of long-term survivors remains necessary.

The effect of weekend and after-hours surgery on morbidity and mortality rates in pediatric neurosurgery patients.

OBJECT: Several studies have indicated that the 30-day morbidity and mortality risks are higher among pediatric and adult patients who are admitted on the weekends. This "weekend effect" has been observed among patients admitted with and for a variety of diagnoses and procedures, including myocardial infarction, pulmonary embolism, ruptured abdominal aortic aneurysm, stroke, peptic ulcer disease, and pediatric surgery. In this study, morbidity and mortality outcomes for emergency pediatric neurosurgical procedures carried out on the weekend or after hours are compared with emergency surgical procedures performed during regular weekday business hours. METHODS: A retrospective analysis of operative data was conducted. Between December 1, 2011, and August 20, 2014, a total of 710 urgent or emergency neurosurgical procedures were performed at Texas Children's Hospital in children younger than than 18 years of age. These procedures were then stratified into 3 groups: weekday regular hours, weekday after hours, and weekend hours. By cross-referencing these events with a prospectively collected morbidity and mortality database, the impact of the day and time on complication incidence was examined. Outcome metrics were compared using logistic regression models. RESULTS: The weekday regular hours and after-hours (weekday after hours and weekends) surgery groups consisted of 341 and 239 patients and 434 and 276 procedures, respectively. There were no significant differences in the types of cases performed (p = 0.629) or baseline preoperative health status as determined by American Society of Anesthesiologists classifications (p = 0.220) between the 2 cohorts. After multivariate adjustment and regression, children undergoing emergency neurosurgical procedures during weekday after hours or weekends were more likely to experience complications (p = 0.0227). CONCLUSIONS: Weekday after-hours and weekend emergency pediatric neurosurgical procedures are associated with significantly increased 30-day morbidity and mortality risk compared with procedures performed during weekday regular hours.

[Cerebrospinal fluid shunts for hydrocephalus and related disorders].

Cerebrospinal fluid (CSF) shunts are commonly employed to treat patients with hydrocephalus. A large number of papers have been published focusing on complications and failures of CSF shunts. However, there appears to be a paucity of knowledge comprehensively covering both common complications and rare ones. In this systematic review, we surveyed articles about surgical complications of CSF shunts as comprehensively as possible. Quantitative analysis was performed to determine the frequency of well-known complications, mortality and revision rates of CSF shunts. Furthermore, rare complications of CSF shunts have also been reviewed.

Clinical evaluation and surveillance imaging in children with spina bifida aperta and shunt-treated hydrocephalus.

OBJECT: Most children with spina bifida aperta have implanted CSF shunts. However, the efficacy of adding surveillance imaging to clinical evaluation during routine follow-up as a means to minimize the hazard of shunt failure has not been thoroughly studied. METHODS: A total of 396 clinic visits were made by patients with spina bifida aperta and shunt-treated hydrocephalus in a spina bifida specialty clinic during the calendar years 2008 and 2009 (initial clinic visit). All visits were preceded by a 6-month period during which no shunt evaluation of any kind was performed and were followed by a subsequent visit in the same clinic. At the initial clinic visit, 230 patients were evaluated by a neurosurgeon (clinical evaluation group), and 166 patients underwent previously scheduled surveillance CT scans in addition to clinical evaluation (surveillance imaging group). Subsequent unexpected events, defined as emergency department (ED) visits and caregiver-requested clinic visits, were reviewed. The time to an unexpected event and the likelihood of event occurrence in each of the 2 groups were compared using Cox proportional hazards survival analysis. The outcome and complications of shunt surgeries were also reviewed. RESULTS: The clinical characteristics of the 2 groups were similar. In the clinical evaluation group, 2 patients underwent shunt revision based on clinical findings in the initial visit. In the subsequent follow-up period, there were 27 visits to the ED and 25 requested clinic visits that resulted in 12 shunt revisions. In the surveillance imaging group, 11 patients underwent shunt revision based on clinical and imaging findings in the initial visit. In the subsequent follow-up period, there were 15 visits to the ED and 9 requested clinic visits that resulted in 8 shunt revisions. Patients who underwent surveillance imaging on the day of initial clinic visit were less likely to have an unexpected event in the subsequent follow-up period (relative risk 0.579, p = 0.026). The likelihood of needing shunt revision and the morbidity of shunt malfunction was not significantly different between the 2 groups. CONCLUSIONS: Surveillance imaging in children with spina bifida aperta and shunted hydrocephalus decreases the likelihood of ED visits and caregiver-requested clinic visits in the follow-up period, but based on this study, its effect on mortality and morbidity related to shunt malfunction was less clear.

Strengthening the argument for rapid brain MR imaging: estimation of reduction in lifetime attributable risk of developing fatal cancer in children with shunted hydrocephalus by instituting a rapid brain MR imaging protocol in lieu of Head CT.

BACKGROUND AND PURPOSE: Children with shunted hydrocephalus have been undergoing surveillance neuroimaging, generally in the form of head CT, for evaluation of ventricular size. As the life expectancy of these children has improved due to better shunt technology and medical care, risks related to the ionizing radiation incurred during multiple head CT examinations that they are expected to undergo throughout their lifetime have become a concern. The purpose of this study is to estimate the LAR of developing fatal cancer due to head CT for ventricular size assessment in children with shunted hydrocephalus and to assess the impact of instituting a rapid brain MR imaging protocol in reducing radiation exposure. MATERIALS AND METHODS: Retrospective review of medical records yielded 182 patients who underwent neuroimaging for assessment of ventricular size. Available neuroimaging studies (head CT and rapid brain MR) were counted and annual neuroimaging frequency was calculated. It was assumed that these patients undergo a similar number of neuroimaging studies annually through 20 years of age. A risk estimate was calculated based on the BEIR VII report and effective doses obtained using the International Commission on Radiologic Protection Report 103 organ weighting factors. RESULTS: The mean annual neuroimaging study frequency was 2.1. Based on the average age of 1.89 years, it was assumed neuroimaging surveillance commences in the second year of life. LAR was calculated assuming that a patient undergoes neuroimaging in the form of head CT at this frequency (2/year) through 20 years of age. Assuming 2 scans are performed per year and the low-dose head CT protocol is used, approximately 1 excess lifetime fatal cancer would be generated per 230 patients; with standard head CT, there would be 1 excess lifetime fatal cancer per 97 patients. CONCLUSIONS: Children with shunted hydrocephalus are at increased risk of developing fatal cancer if they are to undergo surveillance using head CT. Implementation of a rapid brain MR imaging protocol with no radiation detriment will reduce this risk.

Adult outcome of pediatric hydrocephalus.

INTRODUCTION: The outlook of pediatric hydrocephalus has spectacularly improved over the past decades; however, the adult outcome is still poorly documented. Determining the healthcare profile of these patients is important in order to organize the management of this growing population. We decided to review our pediatric hydrocephalus database for pediatric patients treated for hydrocephalus and followed up into adulthood. METHODS: Our institution has a virtual monopoly for pediatric hydrocephalus, serving a four-million-plus population; the transition to adult care is also managed in the same institution. We retrospectively reviewed patients younger than 18 treated for hydrocephalus since 1980 and followed up beyond the age of 20. RESULTS: We reviewed 456 patients, with a mean initial age of 55.6 months, and followed up for a mean of 24.2 years. In 81 patients (17.8%), the last shunt operation occurred after 20 years; 22 of these (4.9% of the total) having never been revised earlier. Sixteen patients (3.5%) could be weaned of their shunt. Thirteen patients died in adult age, 5 of these dying of shunt-related causes. The most prominent sequels were motor (46.5%) and cognitive (47.6%); only 82 patients (18.0%) had no sequel at all. Intelligence quotient values were ≥80 in 54.5% of tested patients; however, schooling was normal in only 41.4%, and only 33.7% was employed in the competitive labor market. CONCLUSION: Adults treated for hydrocephalus in childhood require a life-long follow-up. Late mortality is low but not null, morbidity is high, and many patients require shunt surgery during adulthood. The transition from child to adult neurosurgery needs to be organized for these vulnerable patients.

Communicating hydrocephalus following surgery and adjuvant radiochemotherapy for glioblastoma.

OBJECT: Communicating hydrocephalus is an uncommon complication in patients treated for glioblastoma multiforme (GBM). Its pathogenesis remains unclear. The authors evaluated the clinical and radiological factors associated with the onset of communicating hydrocephalus and the impact of ventriculoperitoneal (VP) shunt surgery on the outcome of these patients. METHODS: One hundred twenty-four patients harboring GBM, who had undergone craniotomy for tumor resection and adjuvant radiochemotherapy, were retrospectively assessed. Seven of them developed communicating hydrocephalus and were treated with VP shunt surgery. Clinical and radiological estimates included Karnofsky Performance Scale (KPS) score, previous surgery, overall survival (OS), CSF pressure and components, tumor location, and leptomeningeal dissemination. RESULTS: All 7 patients who developed communicating hydrocephalus had undergone at least 2 craniotomies for tumor resection before the onset of hydrocephalus (p = 0.0006; Fisher exact test). Six cases showed high levels of CSF proteins. There was a highly significant relationship between ventricular opening at surgery for tumor recurrence and onset of hydrocephalus (p = 0.0002; Fisher exact test). In these patients, VP shunt surgery was followed by a significant improvement of KPS score (p = 0.0180; Wilcoxon signed-rank test). The median OS after VP shunt insertion was 5 ± 2.9 months. CONCLUSIONS: Ventricular opening after radiochemotherapy and high CSF protein levels are significant predictors of communicating hydrocephalus in patients with GBM. The VP shunt surgery improves quality of life in these patients.

Twenty-year outcome in young adults with childhood hydrocephalus: assessment of surgical outcome, work participation, and health-related quality of life.

OBJECT: Shunting of CSF is one of the most commonly performed operations in the pediatric neurosurgeon's repertoire. The 1st decade after initial shunt insertion has been addressed in several previous reports. The goals of the authors' study, therefore, were to determine 20-year outcomes in young adults with childhood hydrocephalus and to assess their health-related quality of life (HRQOL). METHODS: Patients younger than 15 years of age, in whom a first-time shunt insertion was performed for hydrocephalus in the calendar years 1985-1988, were included in a retrospective study on surgical morbidity, mortality rates, academic achievement, and/or work participation. Information concerning perceived health and functional status was assessed using the 36-Item Short Form Health Survey (SF-36) and Barthel Index, which were completed by patients still alive by September 1, 2009. RESULTS: Overall, 138 patients participated, no patient being lost to follow-up. For the 20-year period, the overall mortality rate was 21.7%. The mortality rate was not significantly higher in the 1st decade after initial shunt insertion than in the 2nd decade (p = 0.10). Ten percent of the patients surviving still live with their primary shunt in place, whereas 81% required at least one revision, and among these individual the mean number of revisions was 4.2 (median 3, range 0-26). There was a significantly higher revision rate during the 1st decade after initial shunt insertion compared with the 2nd decade (p = 0.027). The majority of patients live lives comparable with those of their peers. At follow-up, 56% were employed in open-market jobs or were still students, 23% had sheltered employment, and 21% were unemployed. The HRQOL was slightly lower in the hydrocephalic cohort than in the normative population. A significant difference was found in 2 of 8 SF-36 domains-Physical Functioning and General Health. CONCLUSIONS: During the 20-year follow-up period, 81% of the patients required at least one revision of the CSF shunt. The mortality rate was high: 24 patients died in the 1st decade and 6 died in the 2nd decade after implantation of the initial shunt. In total, 4 deaths (2.9%) were due to shunt failure. Shunt placement to treat childhood hydrocephalus has a substantial effect on social functioning in later life, although perceived health was positively found to be better than expected in young adults with hydrocephalus.

Predicting who will benefit from endoscopic third ventriculostomy compared with shunt insertion in childhood hydrocephalus using the ETV Success Score.

OBJECT: The authors recently developed and internally validated the ETV Success Score (ETVSS)--a simplified means of predicting the 6-month success rate of endoscopic third ventriculostomy (ETV) for a child with hydrocephalus, based on age, etiology of hydrocephalus, and presence of a previous shunt. A high ETVSS predicts a high chance of early ETV success. In this paper, they assess the clinical utility of the ETVSS by determining whether long-term survival outcomes for ETV versus shunt insertion are different within strata of ETVSS (low, moderate, and high scores). METHODS: A multicenter, international cohort of children (≤ 19 years old) with newly diagnosed hydrocephalus treated with either ETV (489 patients) or shunt insertion (720 patients) was analyzed. The ETVSS was calculated for all patients. Survival analyses with time-dependent modeling of the hazard ratios were performed. RESULTS: For the High-ETVSS Group (255 ETV-treated patients, 117 shunt-treated patients), ETV appeared to have a lower risk of failure right from the early postoperative phase and became more favorable with time. For the Moderate-ETVSS Group (172 ETV-treated patients, 245 shunt-treated patients), ETV appeared to have a higher initial failure rate, but after about 3 months the instantaneous risk of ETV failure became slightly lower than shunt failure (that is, the hazard ratio became < 1). For the Low-ETVSS Group (62 ETV-treated patients, 358 shunt-treated patients), the early risk of ETV failure was much higher than the risk of shunt failure, but the instantaneous risk of ETV failure became lower than the risk of shunt failure at about 6 months following surgery (the hazard ratio became < 1). CONCLUSIONS: Across all ETVSS strata, the risk of ETV failure becomes progressively lower compared with the risk of shunt failure with increasing time from the surgery. In the best ETV candidates (ETVSS ≥ 80), however, the risk of ETV failure is lower than the risk of shunt failure very soon after surgery, while for less-than-ideal ETV candidates (ETVSS ≤ 70), the risk of ETV failure is initially higher than the risk of shunt failure and only becomes lower after 3-6 months from surgery. These results need to be confirmed by larger, prospective, and preferably randomized studies.

Endoscopic third ventriculostomy vs cerebrospinal fluid shunt in the treatment of hydrocephalus in children: a propensity score-adjusted analysis.

BACKGROUND: Endoscopic third ventriculostomy (ETV) has preferentially been offered to patients with more favorable prognostic features compared with shunt. OBJECTIVE: To use advanced statistical methods to adjust for treatment selection bias to determine whether ETV survival is superior to shunt survival once the bias of patient-related prognostic factors is removed. METHODS: An international cohort of children (< or = 19 years of age) with newly diagnosed hydrocephalus treated with ETV (n = 489) or shunt (n = 720) was analyzed. We used propensity score adjustment techniques to account for 2 important patient prognostic factors: age and cause of hydrocephalus. Cox regression survival analysis was performed to compare time-to-treatment failure in an unadjusted model and 3 propensity score-adjusted models, each of which would adjust for the imbalance in prognostic factors. RESULTS: In the unadjusted Cox model, the ETV failure rate was lower than the shunt failure rate from the immediate postoperative phase and became even more favorable with longer duration from surgery. Once patient prognostic factors were corrected for in the 3 adjusted models, however, the early failure rate for ETV was higher than that for shunt. It was only after about 3 months after surgery did the ETV failure rate become lower than the shunt failure rate. CONCLUSIONS: The relative risk of ETV failure is initially higher than that for shunt, but after about 3 months, the relative risk becomes progressively lower for ETV. Therefore, after the early high-risk period of ETV failure, a patient could experience a long-term treatment survival advantage compared with shunt. It might take several years, however, to realize this benefit.

The prevalence of shunt-treated hydrocephalus: a mathematical model.

BACKGROUND: The aim of the study was to create a mathematical model that reproduces the prevalence of shunt-treated hydrocephalus in the United States over the years and predicts trends in the near future. METHODS: A structured search was performed of the English language literature for case series reporting rates of shunt insertion and revision, shunt removal, and patient mortality. A meta-analytic model was constructed to pool data from multiple studies and to calculate these rates at various time intervals. Separate Markov models were used to predict numbers of shunts at any one time for children (<17 years old) and adults. The models analyze the number of shunts inserted every year since 1955 and follow the likely fates of those patients as time passes. RESULTS: Prevalence rates predicted by the model agree closely with those reported in the literature. However, the model's structure creates considerable variability around point estimates. CONCLUSIONS: The model gives a comprehensive view of the prevalence of shunt-treated hydrocephalus in both children and adults from 1955 to the present. This model may prove useful in predicting resource use and needs for patients with hydrocephalus.

A mathematical model of survival in a newly inserted ventricular shunt.

OBJECT: The object of this study was to mathematically model the prognosis of a newly inserted shunt in pediatric or adult patients with hydrocephalus. METHODS: A structured search was performed of the English-language literature for case series reporting shunt failure, patient mortality, and shunt removal rates after shunt insertion. A metaanalytic model was constructed to pool data from multiple studies and to predict the outcome of a shunt after insertion. Separate models were used to predict shunt survival rates for children (patients < 17 years old) and adults. RESULTS: Shunt survival rates in children and adults were calculated for 1 year (64.2 and 80.1%, respectively), 5 years (49.4 and 60.2%, respectively), and the median (4.9 and 7.3 years, respectively). The longer-term rates predicted by the model agree closely with those reported in the literature. CONCLUSIONS: This model gives a comprehensive view of the fate of a shunt for hydrocephalus after insertion. The advantages of this model compared with Kaplan-Meier survival curves are discussed. The model used in this study may provide useful prognostic information and aid in the early evaluation of new shunt designs and techniques.

Predictors of death in pediatric patients requiring cerebrospinal fluid shunts.

OBJECT: Despite improved therapeutic strategies and better diagnostic techniques in the management of pediatric hydrocephalus there continues to be a significant mortality rate associated with cerebrospinal fluid (CSF) shunts. The goal of this study was to determine the long-term outcome and predictors of death in these patients. METHODS: Data were collected in all patients requiring a CSF shunt presenting to a single tertiary care pediatric institution during a 10-year period. Patients with neoplasms were excluded because their deaths were predominantly related to the tumor. Descriptive statistics were obtained on the patient characteristics, surgical features, and shunt characteristics. The time and cause of death were determined. Kaplan-Meier survival estimates were used to determine overall survival of patients. Univariate analysis was performed using the log-rank test. Multivariate analysis included use of Cox regression model to determine the significance of age (at the time of initial shunt insertion), the number of shunt-related failures and infections, and whether the shunts were complex or multiple in nature in predicting death. Hazard ratios, 95% confidence intervals and probability values were calculated. Of 907 patients, 124 died. The most common causes were myelomeningocele (191 cases), intraventricular hemorrhage (114 cases), and tumor (190 cases) with 7.9, 3.5, and 32.6% dying, respectively, during the study period. Restricting all analyses to cases without neoplasms, the incidence of shunt-related failures was 58.1% in patients who died and 55.3% in those who survived, with an incidence of shunt-related infection of 19.4% in the former and 18.5% in the latter. The overall mortality rates in all patients at 1, 5, and 10 years were 4.5, 8.9, and 12.4%, respectively, from time of initial shunt insertion to death or last follow-up visit. The infection rate per procedure (that is, following the first shunt insertion) was 10.9% (78 of 717 cases). Evaluation of predictors of death revealed a statistically significant effect of infection with a hazard ratio of 1.66 (p = 0.04). CONCLUSIONS: The mortality rate in shunt-treated pediatric patients with hydrocephalus remains high, dependent on the underlying reason for CSF shunt insertion and the subsequent development of infection of the shunt apparatus.

Treatment of hydrocephalus determined by the European Orbis Sigma Valve II survey: a multicenter prospective 5-year shunt survival study in children and adults in whom a flow-regulating shunt was used.

OBJECT: The goal of this study was to evaluate the long-term results of a flow-regulating shunt (Orbis Sigma Valve [OSV] II Smart Valve System; Integra NeuroSciences, Sophia Antipolis, France) in the treatment of hydrocephalus, whether it was a first insertion procedure or surgical revision of another type of shunt, in everyday clinical practice in a multicenter prospective study. METHODS: Patients of any age who had hydrocephalus underwent implantation of an OSV II system. The primary end point of the study was defined as any shunt-related surgery. The secondary end point was a mechanical complication (shunt obstruction, overdrainage, catheter misplacement, migration, or disconnection) or infection. The overall 5-year shunt survival rates and survival as it applied to different patient subgroups were assessed. Five hundred fifty-seven patients (48% of whom were adults and 52% of whom were children) were selected for OSV II shunt implantation; 196 patients reached the primary end point. Shunt obstruction occurred in 75 patients (13.5%), overdrainage in 10 patients (1.8%), and infection in 46 patients (8.2%). The probability of having experienced a shunt failure-free interval at 1 year was 71% and at 2 years it was 67%; thereafter the probability remained quite stable in following years (62% at the 5-year follow-up examination). No difference in shunt survival was observed between the overall pediatric (< or = 16 years of age) and adult populations. In the pediatric age group, however, there was a significantly lower rate of shunt survival in children younger than 6 months of age (55% at the 5-year follow-up examination). CONCLUSIONS: In this prospective study the authors demonstrate the effectiveness of flow regulation in the treatment of hydrocephalus both in children and in adults. Flow-regulating shunts limit the incidence of overdrainage and shunt-related complications. The overall 5-year shunt survival rate (62%) compares favorably with rates cited in other recently published series.

Life expectancy of ventriculosubgaleal shunt revisions.

The subgaleal shunt has been and is currently used for the temporary bypass of the normal cerebrospinal fluid (CSF) pathways. We retrospectively reviewed all subgaleal shunts placed at the Children's Hospital, Birmingham, Ala., USA, from 1993 to the present and examined the life expectancy of revisions of this temporary method of CSF diversion. The average length of survival of primary, secondary and tertiary subgaleal shunts in this population was 37.4, 32.4 and 19.6 days, respectively. This current review demonstrates that the majority of patients in whom a subgaleal shunt is utilized may continue to obtain therapeutic diversion of their CSF for greater than 2.5 months with intermittent subgaleal shunt revisions. In the majority of cases, this length of time is sufficient to manage and resolve issues that would make ventriculoperitoneal shunting undesirable.