1: Z Kinderchir. 1989 Dec;44 Suppl 1:32-4. Links
Ventricular shunting for hydrocephalus following
intraventricular haemorrhage.


Roberts JP,
Burge DM.
Wessex Regional Centre for Paediatric Surgery, Southampton, U.K.
31 patients underwent ventricular shunting (17 VA and 14 VP)
for post-haemorrhagic hydrocephalus over 11 years. The mean
gestational age was 31.8 +/- 4.17 (1 SD) weeks and birth
weight 1.83 +/- 0.77 (1 SD) kg, with no differences between the
VA and VP groups. Shunts inserted less than 5 weeks of age
failed more frequently than those inserted after 5 weeks. There
were 5 early (less than 30 days) blocks all in VP shunts (p =
0.023) but no difference in distal catheter blockage rate (p =
0.14). There were no early infections. In later follow-up, 35% of
patients had block episodes and 22% infective episodes with no
significant difference between the type of shunt used. Overall
mortality was 6.5% and not related to shunt complications.
Revisions were more frequent in VP shunts (0.9 revisions/shunt
year) than VA shunts (0.6 revs/shunt year). Using life table
analysis 60% of VP and 30% of VA shunts failed within 2 years
of insertion.
PMID: 2623959 [PubMed - indexed for MEDLINE]
1: Childs Nerv Syst. 1996 Dec;12(12):748-54. Links
Shunt complications in the first postoperative year in children
with meningomyelocele.



Caldarelli M,
Di Rocco C,
La Marca F.
Department of Neurosurgery, Catholic University Medical School, Rome,
Italy.
The authors analyze the incidence of early mechanical and
infective CSF shunt complications and various factors that might
be correlated with the incidence in a series of 170 children
affected by hydrocephalus and meningomyelocele (MM), with the
aim of the finding to this specific risk factors related to this
particular type of hydrocephalus. Factors investigated for
correlation with CSF shunt malfunction are the following: level of
spinal malformation, age of the patient at MM repair, age at
diagnosis of hydrocephalus, degree of ventricular dilatation, age
at shunt implantation, modality of the surgical procedure,
characteristics of CSF at operation. In the first postoperative
year following CSF shunting, 45.9% of the patients presented
one shunt malfunction, three-quarters of which were due to
mechanical causes, and one quarter to infection. Age of the
patient at diagnosis of hydrocephalus and at CSF shunt
operation did not significantly influence shunt patency, nor did
the surgical modality (programmed vs emergency procedure).
On the other hand, MM level did influence the outcome of CSF
shunting: a higher percentage of malfunctions (and in particular
of infective complications) was observed among the patients
with "high level" MMs than in the group with more caudal
location of the spinal defect. Similarly, the degree of ventricular
dilatation correlated with the incidence of complications (more
severe ventricular dilatation was associated with the highest
incidence of complications). The order in which MM repair and
CSF shunting were carried out and the age of the patients at MM
repair did not affect the occurrence of mechanical complications,
whereas they had a significant effect on the incidence of
infective complications. In fact, the rate of overall complications,
and of infective complications in particular, was proportional the
age at MM repair. Furthermore, the group of children who
underwent to MM repair and CSF shunting simultaneously scored
the lowest percentage of complications, although these were
mainly infections; the highest incidence of complications (and in
particular of infective ones) was observed in the children who
underwent CSF shunting first. The most striking correlation,
however, was found with the characteristics of CSF. While
normal CSF values correlated with an overall incidence of
complications of 39.2%, abnormal CSF values were correlated
with a rate of complications of 90.9%; in particular, the rates of
infective complications were 2.7% and 77.3%, respectively. On
the grounds of these observations a protocol is proposed of
temporary CSF external drainage in children requiring prompt
relief of increased intracranial pressure but at risk for the
presence of a leaking spinal defect or of a MM left unrepaired for
more than 48 h.
PMID: 9118142 [PubMed - indexed for MEDLINE]
Acta Neurochir (Wien). 1995;136(3-4):189-94. Links
Frequency and causes of shunt revisions in different
cerebrospinal fluid shunt types.





Borgbjerg BM,
Gjerris F,
Albeck MJ,
Hauerberg J,
Borgesen SE.
University Clinic of Neurosurgery, Rigshospitalet, Copenhagen, Denmark.
Shunt complications and revisions are common in hydrocephalic
patients treated with a ventriculo-atrial or a ventriculo-peritoneal
shunt. The reported revision rate differs very much but the rate
of revision is close to 50% in many papers. Data from 884
hydrocephalic patients treated with various shunt types in the
period 1958-1989 were recorded retrospectively in order to
evaluate the frequency of revision for various shunt types and
secondly to analyse the specific reasons for the shunt revisions.
The rate of shunt revision was 45%. The Pudenz shunt was
revised more often (62%) than the remaining shunt types. The
Hakim and the Orbis-Sigma shunts had fewer revisions (35%
and 27%, respectively) than the other observed shunt types. A
defect of or an obstruction in the ventricular catheters was a
frequent cause of revision followed by a defect or an obstruction
of the distal catheter, a displacement of the distal catheter and
an acute infection. Because of the higher rate of revision for the
Pudenz shunt the rate of the above mentioned specific
complications is also higher in most of the subgroups for that
specific shunt type. Driven by these experiences it is reasonable
to seek to develop and introduce new shunt types in an attempt
to reduce the complication rate.
PMID: 8748853 [PubMed - indexed for MEDLINE]
ORIGINAL ARTICLE
Year : 2005 | Volume : 72 | Issue : 10 | Page : 843-847
Shunt revision in hydrocephalus
Kumar Raj1, Singh Vinita2, Kumar Marakani V. K.3
1
Department of NeurosurgerySanjay Gandhi Postgraduate Institute of Medical
SciencesLucknow, India
2
Neuroanaesthesiology King George's Medical University, Lucknow, India
3
Department of Neurosurgery Sanjay Gandhi Postgraduate Institute of Medical Sciences
Lucknow, India
Correspondence Address:
Kumar Raj
Associate Professor, Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of
Medical Sciences, Lucknow-226014, UP
India
rajkumar@sgpgi.ac.in
» Abstract
Objective : A retrospective analysis of 50 hydrocephalic children having a minimum followup of 6 months was carried out to see their etiology, clinical features, complications,
incidence of shunt revisions, outcome and the variation from their Western counterparts.
Methods : Clinical features, image findings and treatment of all the cases were recorded from
their discharge summaries. Record of shunt revision complications and outcome was
maintained by the principal author. The data of all the cases were analyzed. Results : The age
of children varied from 1 month to 12 yr (mean 2.2 yr). The most common etiology of
hydrocephalus was aqueductal stenosis in 18 (36%) children. Post infective hydrocephalus,
either of post-tubercular meningitis (TBM) or following bacterial meningitis, remained the
cause in 15 children (30%). Congenital TORCH infection was responsible for 3 cases of
hydrocephalus making infective etiology as the cause in 18 (36%) cases. Intra 4th ventricular
neurocysticercus cyst caused blockade of CSF pathway in 2 children. 15 out of 50 children
required shunt revision, either due to infection (8,16%) or shunt obstruction (7, 14%).
Multiple shunt revisions were required in 2 children only. These revisions were required due
to infection, obstruction or malfunction of the shunt. Conclusions : Infective etiology is
responsible for hydrocephalus in significant number of children (36%). The possibility of
TORCH infection, as a cause of hydrocephalus should be considered even amongst the
children of screened mothers during antenatal check-up. Pure intra 4th ventricular
neurocysticercus cysts (without intraparenchymal cyst), though rare, can manifest with outlet
obstruction. Incidence of shunt revision using Chhabra's medium pressure shunt is very high
in children at an average follow up of 1.6 yr. Post infective hydrocephalus is a major cause of
delayed milestones, contributing to mental retardation.
Keywords: Hydrocephalus; Etiology; Complication; Shunt revision
How to cite this article:
Kumar R, Singh V, Kumar MV. Shunt revision in hydrocephalus. Indian J Pediatr
2005;72:843-847
How to cite this URL:
Kumar R, Singh V, Kumar MV. Shunt revision in hydrocephalus. Indian J Pediatr [serial
online] 2005 [cited 2006 Aug 9];72:843-847. Available
from: http://www.ijppediatricsindia.org/article.asp?issn=00195456;year=2005;volume=72;issue=10;spage=843;epage=847;aulast=Kumar
Hydrocephalus has been the focus of more dedicated study and investigation than perhaps any
other condition afflicting the human nervous system. For many centuries patients with
hydrocephalus had limited expectations for survival. With the development and refinements
of modern cerebrospinal fluid (CSF) shunt, normal learning and intelligence is now possible
and patients are able to enjoy full participation in all facets of life. CSF shunt diversions
though have many complications, the most common being shunt obstructions and infection
which require the attention of neurosurgeons. The frequency of shunt revisions in the 1st year
and in the 10th yr have been studied in detail amongst the hydrocephalic children harbouring
spinal dyspraphism[1], where 30-40% children require at least one shunt revision during first
years of life; of these 15 to 20% require multiple revisions and 85% undergo at least one shunt
revision during first 10 yr.[1] However, the incidence of shunt revision is not known in other
hydrocephalic children. The present study is a retrospective analysis of hydrocephalic
children who had undergone CSF shunt diversion. The etiology, clinical profile and
complication of shunt procedures are studied in the Indian children. The frequency of shunt
revisions and their outcome has also been studied.
» Materials and Methods
Analysis of a cohort of 50 children of hydrocephalus retrospectively, who underwent a
ventriculoperitoneal shunt insertion during 1997 to 2001 in the Neurosurgery Department at
Sanjay Gandhi Post Graduate Institute of Medical Sciences, India was done. The following
details were ascertained from the case record files, discharge summaries and follow-up
register maintained by a pediatric neurosurgeon : name, age, sex, etiology, clinical profile,
imaging and treatment. Record of shunt revisions, complications and outcome at follow-up of
each case was maintained in the computer database and follow-up register.
Children having a minimum follow-up of 6 months were included in this analysis and those
with an adequate follow-up but inadequate records (etiology, procedure, complications and
follow-up) were excluded. Children with active signs of meningeal irritation, and tumors as
the cause of hydrocephalus were also excluded. Children included in the analysis underwent
medium pressure Chhabra's shunt, either by the principal author himself or under his direct
supervision, particularly when the procedure was performed electively. Chhabra's shunt is
made up of implant grade silastic material and has a ventricular end, a chamber and a
peritoneal end. The chamber has a spring in slit. The CSF flow is pressure regulated and flow
rate type. There are around 40 holes in the 1.5cm length of the radio-opaque ventricular end.
The peritoneal end is also radio-opaque. It is an economically sound shunt used widely
throughout India as well as in the neighboring countries.
The clinical features of children in study are summarized in [Table - 1].
» Results
The fifty children included in the study comprised of 42 males and 8 females with a ratio of
5.25: 1. The age at the time of shunt insertion for the first time ranged from 1 month to 12 yr
(mean 2.2 yr). Follow-up ranged from 6 months to 2 yr (mean 1.6 yr). Each child had
undergone an initial CT scan. MRI was performed in cases where there was a suspicion of a
structural lesion causing hydrocephalus. The causes of hydrocephalus amongst the children in
this study are mentioned in [Table - 2].
The children of TORCH infection were diagnosed by presence of periventricular calcification
[Figure - 1]. The diagnosis was confirmed by serum and CSF ELISA.
Both the children of neurocysticercus cyst had history of tonic clonic seizures along with
raised intracranial pressure (ICP). Emergency shunt was inserted in one of these as he
presented acutely with altered sensorium and features of raised ICP, the cyst was enucleated
at a later date in this child [Figure - 2]. An elective shunt was performed in the other child,
where the cyst could not be defined at the first presentation on CT scan. The 4th ventricular
cyst was enucleated when the child had a suspected shunt malfunction at 9 months, when CTscan also confirmed the diagnosis.
A single premature baby of 7 months gestational age having a birth weight of 1500gm was
diagnosed to have hydrocephalus 1 month following birth due to intraventricular hemorrhage.
An elective ventricular tap revealed xanthochromic CSF, suggesting an old bleed, further
confirmed by biochemical and cytological analysis. Within a period of 4 months, shunt
revision was required twice due to shunt blockade on him. The child remained mentally
deprived at 1-year follow-up.
Two of four children with Dandy Walker malformation had mental retardation at follow-up,
though there was no evidence of structural anomalies of the cortex.
Complications
Fifteen of the fifty cases required shunt revisions during a mean follow-up of 1.6 yr due to
one or the other reason. Two of these 15 cases required multiple shunt revisions (1 child of
meningomyelocele had 5 shunt revisions in a period of 8 months and 1 with an
intraventricular hemorrhage had two shunt revisions in a period of 4 months). Shunt infection
was the first and foremost cause of shunt revisions in 8 (16%) children (0.16 per case and 0.14
per procedure). Shunt obstruction was the second cause in 7(14%) children (abdominal end of
the shunt getting blocked in 2 and ventricular end in 5).
Three of 8 shunt infections developed wound dehiscence at 9 weeks in one child and at 2
months in the other 2 children. Scalp wound demonstrated growth of staphylococcus
epidermidis and the peritoneal wound showed E. coli and pseudomonas on culture. Two of
the 8 children developed infection of subdural hygroma along with shunt infection. Three of
the 8 children presented with meningismus and fever for a few days to weeks duration.
Features of raised intracranial pressure and pericatheteral CSF filling due to occult leak from
ventricular end were the manifestations in two other children. One of these two had episodic
tonic posturing of the body for a month along with left hemiparesis. Loss of bilateral vision
and secondary optic atrophy was noted in another child of aqueductal stenosis who had
undergone ventriculoperitoneal shunt 1.8 yr ago. All the 8 children were treated either by
exteriorization of shunt or by installing omaya reservoir, followed by intermittent tapping.
External ventricular drainage was maintained till CSF cytochemical analysis, microscopy and
culture sensitivity proved an absence of infection. Antibiotics were given for 4-6 weeks (even
if CSF was sterile) on the basis of culture and sensitivity of CSF, shunt tubes or wound swabs.
Both ends of the removed shunt tube were subjected to culture and sensitivity in all cases of
shunt removal. In the event of sterile CSF, broad spectrum antibiotic like cefotaxim/amikacin
and metronidazole were given in an injectable form for 2 to 3 weeks, followed by broadspectrum oral therapy for further 3 - 4 weeks. In severe infection of CSF, intraventricular
gentamicin was given on alternate days. Reinstallation of a new shunt assembly was done
only after two consecutive CSF samples came out to be normal biochemically and
cytologically.
Outcome
Thirty-five of the 50 children had no complication following shunt insertion and improvement
was noted in neurological/functional status of the subjects at follow-up. Analysis of the
neurological/functional outcome revealed that 15 of the 50 cases continued to have delayed
milestones at follow-up and they required some sort of functional assistance in their day-today activities. On the basis of etiology, 3 of these 15 had a congenital infection, 5 with posttubercular meningitis, 2 with nontubercular bacterial infections, 2 with Dandy walker
syndrome, 2 had an associated spinal dysraphism and 1 had an intraventicular hemorrhage.
Results reveal that children with an infectious etiology (post-infective n=15, congenital
infection n=3) had a higher incidence of dependence on their families for their day-to-day
activities in comparison to other etiologies of hydrocephalus (10 of 18 infective etiology were
dependent, 55.6%).
» Discussion
Most infants presenting with progressive hydrocephalus are treated either with
ventriculoperitoneal shunt CSF diversion or 3rd ventriculostomy. Although the risk in
performing a shunt is low, complications related to shunt diversion are many, hence each
child needs to be assessed individually, weighing the risk of surgery vs no treatment. The
outcome of shunt diversion depends on a number of factors which include concomitant
medical problems, the degree of neurologic compromise at the time of surgery, the nature,
etiology, duration and severity of hydrocephalus, status of cortical mantle, structural
anomalies, timing of shunt etc[1].
Etiological Factors and Their Relation to the Outcome
Amongst the etiological factors, congenital aqueductal stenosis accounts for 10% of all
hydrocephalus cases in children.[1] Aqueductal stenosis remained the most common cause of
hydrocephalus amongst children in the present study as well (n = 18, 36%). A higher
incidence can be explained on account of the exclusion criteria in the present study, where
idiopathic cases, tumors etc as a cause of hydrocephalus were excluded. None of these
children showed mental retardation. All children of school age attended school normally and
were not dependent on their families for their day-to-day activities.
Tuberculosis is a serious health problem in the developing countries. Most patients with
central nervous system tuberculosis have an identifiable systemic disease. Hydrocephalus
develops more frequently in these patients and almost always manifests itself within 4 - 6
weeks of the disease[2],[3]. In the present cohort of hydrocephalic children, 10 (20%) had
post TBM hydrocephalus. All cases responded well to antitubercular therapy with CSF
diversion. The older children manifested with mental retardation or delayed milestones,
probably due to extensive involvement of brain parenchyma and delayed shunting in them,
and they lagged behind their siblings in school at follow-up.
Hydrocephalus is an uncommon complication of childhood bacterial meningitis but occurs
more frequently in neonates recovering from meningitis. In most cases, the complication
develops insidiously over weeks to months. Severe neurologic sequelae such as
hemiplegia/quadriplegia, hyperactivity and mental retardation are relatively uncommon in
these patients (less than or equal to 4% of all children recovering from bacterial meningitis),
although such sequelae are relatively more frequent after neonatal meningitis[1]. Five of the
50 children in the present study had nontubercular meningitis as the cause for their
hydrocephalus. One of these patients had hemiplegia and 2 showed mental retardation at
follow-up even after shunting.
Cytomegalovirus, rubella, mumps, varicella, and parainfluenza virus can cross the placenta
and have been implicated as a cause of congenital hydrocephalus. Congenital infection
(TORCH) was the cause of hydrocephalus in 3 children in the present study (6%). All these
children showed delayed milestone at follow-up.
Neurocysticercosis is a leading cause of seizures, hydrocephalus and learning disability in
children and adults.[4],[5] In the present study, 2 of 50 children, had 4th ventricular outlet
obstruction due to neurocysticercus cysts. Enucleation of the cyst from the 4th ventricle was
done in 1 child who had undergone an emergency VP shunt at presentation, while in the other
the cyst was enucleated 9 months later, when he presented with shunt malfunction. At followup both of them were doing well in school and showed no mental retardation or neurological
compromise.
The influence of the etiology of hydrocephalus on outcome has been studied by various
authors with differing conclusions, which no doubt reflects the heterogenesity of the
underlying conditions.[6],[7] In this analysis etiology did influence the outcome significantly,
as the children with hydrocephalus secondary to infections were more than 3 times likely to
require assistance in their day to day activities (55.6% vs 15.6%), as compared to the other
diagnostic categories (as shown in literature[8]. The present results, however, did not confirm
the finding of a higher incidence of poor intellectual outcome in aqueduct stenosis or noncommunicating hydrocephalus.[6]
Complications of Shunt
Shunt obstruction has been found to be one of the important causes of shunt failure requiring
revision. The most common shunt malfunction was found to be at the ventricular catheter as
reported in literature[9]. In the present study mean follow-up period of 1.6 yr, 5 of 7(71%)
shunt obstruction cases had a proximal block of ventricular end. Distal obstruction is seen
principally if the distal end is placed in the pre-peritoneal space. Low-grade infection with
intra-abdominal loculation or pseudocyst formation, disconnection, ingestion and withdrawal
of the catheter from the peritoneum are the other causes of distal malfunction[10]. Two
children in the present analysis demonstrated block at the peritoneal end, most probably with
mental tissue, where the distal tubes started to drain once the peritoneal tips were cut.
Most centers report infection rates in the order of 5 to 10%.[1] These infections usually
present within two months of shunt insertion, suggesting that most of these occur during the
surgery itself.[11] The infection rate in the present study is 16% (n=8), (0.16 per case and
0.14 per procedure) in the mean follow-up period of 1.6 yr. This is quite disappointing by the
present standards[12] and reflect that the children under 6 months (n=21, 42%) are
significantly at risk for infective complications. According to etiology and clinical
presentation the shunt infection has been divided into external and internal type. Though the
manifestations of both are different, a few of them may present with atypical manifestations
not coinciding with either of the two. Two children in the present study presented with
atypical manifestations of shunt infection like diffuse pericatheteral swelling and globular
swelling at the ventricular end[13].
Organisms of low virulence generally cause infection of CSF shunts. Staphylococcus
epidermidis is the most commonly found organism in most series[14]. Staphylococcus aureus,
Gram-negative bacilli, and mixed infections are the next most common agents encountered. In
the present analysis, 6 out of the 8 children showed shunt infection due to staphylococcus
species and the rest 2 had infection due to pseudomonas and E. coli species. Infection was
managed by the removal of the infected shunt assembly and placement of omaya reservoir
(for regular tapping of CSF) or external ventricular drainage if need arose. A course of 4 to 6
weeks antibiotics was chosen on the basis of culture and sensivity of CSF, shunt tubes or
wound swabs, and broad-spectrum antibiotics were administered if cultures failed to reveal
any pathogen. Intraventricular antibiotics were also administered in severe infections. A new
shunt assembly was installed once the CSF became clear biochemically and microscopically
on two consecutive testing. If the CSF is flowing through the shunt more quickly, the ability
of the brain to expand, the cortical mantle, may remain unexpanded and subdural fluid
collections may develop. In the present study, two children had subdural hygroma due to
overdrainage of CSF. This incidence might have been higher in the present series but we
could document only two symptomatic cases mainly because of adventitious infection.
Being a retrospective analysis, the study suffers from its own set of limitations. A short
follow-up is an unacceptable compromise to the ideal situation of a prospective study. The
validity of this study could also be improved by recruiting large number of patients. But
practically, this was possible only in a multicenter study, as follow-up is a real problem in the
developing milieu.
» Conclusion
The development of effective cerebrospinal fluid (CSF) shunts represents a landmark in
neurosurgery. Apart from congenital aqueductal stenosis, post-infective hydrocephalus
remains the commonest cause of hydrocephalus in developing countries. Treatable cause like
TORCH infection in the mother may manifest with hydrocephalus in the newborn and this is
accountable to inappropriate antenatal screening, immunization and ignorance. Intra 4th
ventricular neurocysticercus cyst may rarely contribute to the blockade of CSF pathway
without the evidence of any other cyst in parenchyma or ventricular system.
Complications of shunt, like infection and obstruction are quite disappointing and have a high
incidence of around 30% to warranting shunt revisions. Delayed milestones, mental
retardation and dependence for day-to-day activities are more marked with the infective
etiology of hydrocephalus.
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