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Background: Cerebrospinal fluid (CSF) shunt infection is a major cause of morbidity and mortality in the treatment of hydrocephalus and is associated with significant medical cost. Several studies have demonstrated the efficacy of antibiotic-impregnated (AI) shunt catheters in reducing CSF shunt infection; however, providers remain reluctant to adopt AI catheters into practice because of the increased upfront cost. The objective of this study was to determine if the use of AI catheters provided cost savings in a large nationwide database., Methods: Hospital discharge and billing records from the Premier Perspective Database from 2003-2009 were retrospectively reviewed to identify all adult and pediatric patients undergoing de novo ventricular shunt placement. The incidence of shunt infection within 1 year of implantation was determined. Shunt infection-related cost was defined as all inpatient billing costs incurred during hospitalization for treatment of shunt infection., Results: In 287 U.S. hospitals, 10,819 adult (AI catheters, 963; standard catheters, 9856) and 1770 pediatric (AI catheters, 229; standard catheters, 1541) patients underwent ventricular shunt placement. AI catheters were associated with significant reduction in infection for both adult (2.2% vs. 3.6%, P = 0.02) and pediatric (2.6% vs. 7.1%, P < 0.01) patients. Total infection-related costs were $17,371,320 ($45,714 ± $49,745 per shunt infection) for adult patients and $6,508,064 ($56,104 ± $65,746 per shunt infection) for pediatric patients. Infection-related cost per 100 de novo shunts placed was $120,534 for AI catheters and $162,659 for standard catheters in adult patients and $165,087 for AI catheters and $395,477 for standard catheters in pediatric patients., Conclusions: In analysis of this large, nationwide database, AI catheters were found to be associated with a significant reduction in infection incidence, resulting in tremendous cost savings. AI catheters were associated with a cost savings of $42,125 and $230,390 per 100 de novo shunts placed in adult and pediatric patients, respectively., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Object: The real-world effectiveness of antibiotic-impregnated shunt catheters to reduce the incidence of shunt infections is still debated. The literature to date consists mostly of small, single-institution studies. The aim of this study was to assess the incidence of infection for antibiotic-impregnated catheters (AICs) versus standard shunt catheters in a large nationwide administrative database., Methods: The authors retrospectively reviewed hospital discharge and billing records from the Premier Perspective Database from April 2003 to July 2009 to identify all adult and pediatric patients undergoing de novo ventricular shunt placement. The primary end point was the incidence of shunt infection within 1 year of implantation. Multivariate logistical regression was performed to determine factors associated with increased incidence of infection., Results: A total of 10,819 adult (AIC, 963; standard catheter, 9856) and 1770 pediatric (AIC, 229; standard catheter, 1541) patients underwent ventricular shunt placement in 287 US hospitals. Overall, the incidence of infection was 3.5% in adults (n=380) and 6.6% in pediatric patients (n=116). AICs were associated with significant reduction in infection for both adult (2.2% vs 3.6%, p=0.02) and pediatric (2.6% vs 7.1%, p<0.01) patients. AIC use was associated with reduced infection regardless of hospital size, annual shunt volume, hospital location, or patient risk factors and remained associated with a reduced infection in multivariate analysis for both adult (p=0.02) and pediatric (p=0.02) patients., Conclusions: The use of antibiotic-impregnated shunt catheters was associated with a reduction in shunt infections for both adult and pediatric patients. This provides further support that AICs may represent a reliable means of reducing shunt infections for both adult and pediatric patients.

Object: Despite multiple preventive strategies for reducing infection, up to 15% of patients with shunt catheters and 27% of patients with external ventricular drains (EVDs) may develop an infection. There are few data on the cost-effectiveness of measures to prevent hydrocephalus catheter infection from the hospital perspective. The objective of this study was to perform a cost-consequence analysis to assess the potential clinical and economic value of antibiotic-impregnated catheter (AIC) shunts and EVDs compared with non-AIC shunts and EVDs in the treatment of hydrocephalus from a hospital perspective., Methods: The authors used decision analytical techniques to assess the clinical and economic consequences of using antibiotic-impregnated shunts and EVDs from a hospital perspective. Model inputs were derived from the published, peer-reviewed literature. Clinical studies comparing infection rates and the clinical and economic impact of infections associated with the use of AICs and standard catheters (non-AICs) were evaluated. Outcomes assessed included infections, deaths due to infection, surgeries due to infection, and cost associated with shunt- and EVD-related infection. A subanalysis using only AIC shunt and EVD Level I evidence (randomized controlled trial results) was conducted as an alternate to the cumulative analysis of all of the AIC versus non-AIC studies (13 of the 14 shunt studies and 4 of the 6 EVD studies identified were observational). Sensitivity analyses were conducted to determine how changes in the values of uncertain parameters affected the results of the model., Results: In 100 patients requiring shunts, AICs may be associated with 0.5 fewer deaths, 71 fewer hospital days, 11 fewer surgeries, and $128,228 of net savings in hospital costs due to decreased infection. Results of the subanalysis showed that AICs may be associated with 1.9 fewer deaths, 1611 fewer hospital days, 25 fewer surgeries, and $346,616 of net savings in hospital costs due to decreased infection. The rate of decrease in infection with AIC shunts was shown to have the greatest impact on the cost savings realized with use of AIC shunts. In 100 patients requiring EVDs, AICs may be associated with 2.7 fewer deaths and 82 fewer hospital days due to infection. The relative risk of more severe neurological impairment was estimated to be 5.33 times greater with EVD infection. Decreases in infection with AIC EVDs resulted in an estimated $264,069 of net savings per 100 patients treated with AICs. Results of the subanalysis showed that AIC EVDs may be associated with 1.0 fewer deaths, 31 infection-related hospital days averted, and $74,631 saved per 100 patients treated with AIC EVDs. As was seen with AIC shunts, the rate of decrease in infection with AIC EVDs was shown to have the greatest impact on the cost savings realized with use of AIC EVDs., Conclusions: The current value analysis demonstrates that evidence supports the use of AICs as effective and potentially cost-saving treatment.

Background: External ventricular drainage (EVD) catheters provide reliable and accurate means of monitoring intracranial pressure and alleviating elevated pressures via drainage of cerebrospinal fluid (CSF). CSF infections occur in approximately 9% of patients. Antibiotic-impregnated (AI) EVD catheters were developed with the goal of reducing the occurrence of EVD catheter-related CSF infections and their associated complications., Objective: To present an international, prospective, randomized, open-label trial to evaluate infection incidence of AI vs standard EVD catheters., Methods: Infection was defined as (1) proven infection, positive CSF culture and positive Gram stain or (2) suspected infection: (A) positive CSF culture with no organisms identified on initial Gram stain; (B) negative CSF culture with a gram-positive or -negative stain; (C) CSF leukocytosis with a white blood cell/red blood cell count >0.02., Results: Four hundred thirty-four patients underwent implantation of an EVD catheter. One hundred seventy-six patients in the AI-EVD cohort and 181 in the standard EVD catheter cohort were eligible for evaluation of infection. The 2 groups were similar in all clinical characteristics. Proven infection was documented in 9 (2.5%) patients (AI: 4 [2.3%] vs standard: 5 [2.8%], P = 1.0). Suspected infection was documented in 31 (17.6%) patients receiving AI and 37 (20.4%) patients receiving standard EVD catheters, P = .504. Duration of time to suspected infection was prolonged in the AI cohort (8.8 ± 6.1 days) compared with the standard EVD cohort (4.6 ± 4.2 days), P = .002., Conclusion: AI-EVD catheters were associated with an extremely low rate of catheter-related infections. AI catheters were not associated with risk reduction in EVD infection compared to standard catheters. Use of AI-EVD catheters is a safe option for a wide variety of patients requiring CSF drainage and monitoring, but the efficacy of AI-EVD catheters was not supported in this trial.

Background: Cerebrospinal fluid (CSF) shunt infection remains a major cause of morbidity and mortality in the treatment of hydrocephalus. Studies have demonstrated the efficacy of antibiotic-impregnated shunt (AIS) systems in reducing CSF shunt infections in pediatric patients. Fewer studies evaluate the efficacy of AIS systems in adult hydrocephalus., Objective: : To determine whether categorical conversion to AIS shunt systems reduced the incidence of shunt infection in adults., Methods: All adult patients undergoing CSF shunt insertion over a 7-year period were retrospectively reviewed (2004-2009). In 2006, a categorical switch to AIS catheters was made. Before 2006, standard nonimpregnated shunt catheters were used. We retrospectively reviewed the first 250 cases of AIS catheter implantation and compared them with the immediately preceding 250 non-AIS cases to assess 1-year incidence of CSF shunt infection., Results: Five hundred shunt surgeries were performed for normal-pressure hydrocephalus in 378 patients (76%), pseudotumor cerebri in 83 patients (17%), and various obstructive/communicating hydrocephalus etiologies in 40 patients (8%). All patients were followed for 12 months. The mean age was 60 ± 18 years. Baseline characteristics were similar between AIS (n = 250) and non-AIS (n = 250) cohorts. Overall, 13 patients (2.6%) experienced CSF shunt infection, occurring a mean of 2 ± 2 months postoperatively. Shunt infection incidence was decreased in AIS (1.2%) vs non-AIS (4.0%) cohorts (P = .0492). Staphylococcus epidermidis was the most common pathogen in AIS and non-AIS cohorts. Oxacillin resistance was not increased in the AIS cohort., Conclusion: Categorical conversion to AIS catheters was associated with a reduced incidence of shunt infection. AIS catheters may be a reliable instrument for decreasing perioperative shunt colonization and subsequent infection in adults with hydrocephalus.

Object: Cerebrospinal fluid shunt infections are associated with significant morbidity and mortality in the treatment of adult and pediatric hydrocephalus. Antibiotic-impregnated shunt (AIS) catheters have been used with the aim of reducing shunt infection. While many studies have demonstrated a reduction in shunt infection with AIS, this reported efficacy has varied within the literature., Methods: The authors performed a systematic literature review to identify all published articles comparing the incidence of CSF shunt infection in AIS versus non-AIS catheters. The incidence of infection for AIS versus non-AIS catheters was calculated using the Mantel-Haenszel common odds ratio, and baseline demographics were compared between AIS and non-AIS cohorts., Results: Twelve AIS versus non-AIS cohort comparisons were identified in the literature (5 pediatric hydrocephalus, 3 adult hydrocephalus, and 4 mixed populations). In a total of 5613 reported shunt procedures (2664 AISs vs 2949 non-AISs), AISs were associated with a reduction in shunt infection (3.3% vs 7.2%; OR 0.439, p < 0.0001). In 787 shunt procedures for adult hydrocephalus (427 AIS vs 360 non-AIS), AISs were associated with reduction in shunt infection (0.9% vs 5.8%; OR 0.153, p < 0.0001). In 1649 shunt procedures for pediatric hydrocephalus (854 AIS vs 795 non-AIS), AISs were associated with reduction in shunt infection (5.0% vs 11.2%; OR 0.421, p < 0.0001)., Conclusions: The authors' systematic review of the literature demonstrates that AIS catheters are associated with a significant reduction over non-AIS catheters in the reported incidence of CSF shunt infection in adult and pediatric populations. The AIS catheters do not appear to be associated with an increased incidence of antibiotic-resistant microorganisms. Prospective, randomized trials are needed to firmly assess and confirm this apparent difference in infection incidence.

Objective: To determine if use of antibiotic-impregnated shunt (AIS) systems to reduce cerebrospinal fluid (CSF) shunt infections in adult patients with hydrocephalus has been cost-effective at one institution., Methods: All adult patients undergoing CSF shunt insertion over a 7-year period at the Johns Hopkins Hospital were retrospectively reviewed (2004-2009). In 2006, a categorical switch to AIS catheters was made. Before 2006, standard nonimpregnated shunt catheters were used. The 1-year incidence of shunt infection was retrospectively assessed and accounting and billing records were reviewed to determine shunt infection-related medical costs for patients undergoing AIS vs non-AIS shunt surgery., Results: A total of 500 (250 AIS, 250 non-AIS) shunt surgeries were performed for normal-pressure hydrocephalus (NPH) (n = 378 [76%]), pseudotumor cerebri (n = 83 [17%]), and various obstructive and communicating hydrocephalus etiologies (n = 40 [8%]). The incidence of shunt infection was decreased in the AIS (1.2%) vs non-AIS (4.0%) cohorts (P = .0492. Overall, the mean cost per shunt infection was $40,371. Per 250 shunts placed, the total infection-related cost was reduced from $321,407 to $203,424 after the conversion to AIS catheters. AIS catheters were associated with direct cost savings of $47,193 per 100 shunt surgeries performed., Conclusions: In a retrospective cohort study of 500 CSF shunt surgeries performed in adult patients with hydrocephalus, this institution's categorical conversion to AIS catheters was associated with a significant reduction in infection-related medical costs within the first year after surgery. Although prospective randomized cost-utility studies are needed to confirm these observations, these results suggest that AIS catheters are cost-effective in the treatment of hydrocephalus in adult patients., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Introduction: Because of the difficulty in distinguishing idiopathic normal pressure hydrocephalus (INPH) from other neurodegenerative conditions unrelated to cerebrospinal fluid (CSF) dynamics, response to CSF shunting remains highly variable. We examined the utility of CSF drainage and CSF pressure (Pcsf) dynamics in predicting response to CSF shunting for patients with INPH., Methods: Fifty-one consecutive INPH patients underwent continuous lumbar Pcsf monitoring for 48 hours followed by 72 hours of slow CSF drainage before ventriculoperitoneal shunting. Response to CSF drainage and B-wave characteristics were assessed via multivariate proportional-hazards regression analysis., Results: Improvement in 1, 2, or all 3 INPH symptoms was observed in 35 (69%), 28 (55%), and 11 (22%) patients, respectively, after CSF shunt implantation by 12 months after surgery. A positive response to CSF drainage was found to be an independent predictor of shunt responsiveness (relative risk, 0.30; 95% confidence interval, 0.09-0.98; P = 0.05). There was no difference in Pcsf wave characteristics between the shunt-responsive and -nonresponsive groups, regardless of whether 1-, 2-, or 3-symptom improvement was used to define response to CSF shunting., Conclusion: In this study of 51 INPH patients who underwent Pcsf monitoring with waveform analysis and CSF drainage followed by shunt surgery, there was no correlation between specific Pcsf wave characteristics and objective symptomatic improvement after shunt placement. Pcsf monitoring with B-wave analysis contributes little to the diagnostic dilemma with INPH patients. Clinical response to continuous CSF drainage over a 72-hour period suggests a high likelihood of shunt responsiveness.

Objective: Antibiotic-impregnated shunt (AIS) systems have been designed to prevent the colonization of shunt components by skin flora that occurs at surgery. Although such systems may decrease the incidence of early shunt infections (those occurring within 6 months of shunt placement), it is unclear if such exposure to prolonged antibiotics leads to an increased incidence or virulence of late shunt infections (those occurring later than 6 months after shunt placement). In this study, the authors evaluate the incidence of late shunt infection after the introduction of an AIS system in a pediatric hydrocephalus population., Materials and Methods: We prospectively reviewed all pediatric patients undergoing antibiotic-impregnated CSF shunt insertion or shunt revision operations at our institution for the 33 month period between October 1, 2002 and June 31, 2005. All shunt-related complications, including shunt infection, were evaluated in those patients with later than 6 months of follow-up., Results: A total of 153 pediatric patients (between 1 and 21 years of age) underwent 262 shunting procedures involving the use of antibiotic-impregnated catheters. All patients were followed-up for later than 6 months with a mean follow-up of 21.7 months (range 13-46 months). Ten patients (3.82%) experienced an early shunt infection within the 6-month follow-up period. No patients experienced a late shunt infection., Conclusion: Although concern exists that AIS systems may delay shunt infections or even increase the rate or virulence of such infections, introduction of such catheters into a pediatric hydrocephalus cohort does not significantly increase incidence of late CSF shunt infection compared to historic controls.

Object: Antibiotic-impregnated shunt (AIS) systems may decrease the incidence of cerebrospinal fluid (CSF) shunt infections. However, there is a reluctance to use AIS components because of their increased cost. In the present study the authors evaluated factors contributing to the medical costs associated with the treatment of CSF shunt infections in a hydrocephalic pediatric population, those implanted with AIS systems compared with those implanted with standard shunt systems., Methods: The authors retrospectively reviewed data obtained in all pediatric patients who had undergone CSF shunt insertion at their institution over a 3-year period. All patients were followed up for 12 months after surgery. The independent association between AIS catheter use and subsequent shunt infection was assessed by performing a multivariate proportional hazards regression analysis. Factors contributing to the medical costs associated with shunt infection were evaluated., Results: Two hundred eleven pediatric patients underwent 353 shunting procedures. Two hundred eight shunts (59%) were placed with nonimpregnated catheters and 145 shunts (41%) were placed with AIS catheters. Twenty-five patients (12%) with non-AIS catheters experienced shunt infection, whereas only two patients (1.4%) with AIS catheters had a shunt infection within the 6-month follow-up period (p < 0.01). Among infected patients, infected patients with standard shunt components had a longer average hospital stay, more inpatient complications related to infection treatment, and more multiple organism infections and multiple antibiotic regimens, compared with those with AIS components., Conclusions: Although individual AIS components are more expensive than standard ones, factors contributing to medical costs are fewer in pediatric patients with infected shunts when the components are antibiotic-impregnated rather than standard.

Introduction: The use of programmable shunt valves has increased dramatically in the practice of pediatric hydrocephalus. Despite theoretical advantages, it remains unclear if the use of programmable vs set-pressure valves affects shunt outcome., Materials and Methods: The clinical and radiological records of all pediatric patients undergoing ventriculoperitoneal (VP), ventriculopleural (VPl), and ventriculoatrial (VA) shunt surgery from 2001 to 2004 at an academic institution were reviewed. The association of programmable vs set-pressure valves with subsequent shunt revision was assessed by Kaplan-Meier shunt survival plots and log-rank analysis., Results: A total of 279 VP, VPl, and VA shunt surgeries were performed on patients with median (interquartile range) age of 4 (1-14) years (161 male, 118 female; 158 communicating, 122 obstructive hydrocephalus). Programmable valves were used in 76 (27%) cases and set-pressure valves in 203 (73%). At mean+/-SD follow-up of 17 +/- 13 months, programmable vs set-pressure valves were associated with reduced risk of both overall shunt revision [26 (35%) vs 109 (54%); relative risk (RR) (95% CI); 0.61 (0.41-0.91), p = 0.016] and proximal obstruction [9 (12%) vs 58 (28%); RR (95% CI); 0.39 (0.27-0.80), p = 0.006]. There was no difference in distal obstruction [3 (4%) vs 11 (5%) cases], infection [6 (8%) vs 12 (6%) cases], valve obstruction [0 (0%) vs 4 (2%)], or shunt disconnection [2 (3%) vs 1 (1%)] between adjustable and set-pressure valves, respectively., Conclusion: In our experience, the use of programmable vales was associated with a decreased risk of proximal shunt obstruction and shunt revision. Programmable valves may be preferred in patients frequently experiencing proximal shunt failure. A prospective, controlled study is warranted to evaluate the potential value of adjustable vs set-pressure valve systems.

Introduction: Endoscopic third ventriculostomy (ETV) is accepted as an effective treatment for obstructive hydrocephalus (OHC); however, its benefit in patients previously treated with cerebrospinal fluid (CSF) shunting remains unclear. The value of concurrent ETV and ventriculoperitoneal (VP) shunting in patients with frequent shunt failure remains unstudied., Methods: Outcomes were compared between OHC patients receiving ETV as initial CSF diversion treatment (n= 19) versus OHC patients receiving ETV for shunt failure (n= 11) by log-rank analysis and Kaplan-Meier plots of recurrence-free periods. To determine if the performance of ETV with concurrent shunt revision decreased the incidence of catastrophic treatment failure in patients experiencing frequent and emergent shunt failures (n = 8), the time to treatment failure after ETV and shunt revision was compared with the mean duration of their previous CSF shunts., Results: ETV after shunt failure was 2.5-fold more likely to fail [risk ratio (RR): 2.48, p<0.05] versus ETV as initial CSF diversion treatment for OHC. Following ETV as initial CSF diversion treatment, 17 patients (89%) experienced immediate improvement and 65% remained recurrence-free at year 2. Following ETV after shunt failure, 16 patients (71%) experienced immediate improvement, but only 25% remained recurrence-free at year 2. In patients with a history of multiple shunt revisions and complications, concurrent use of ETV and VP shunt did not significantly decrease treatment failure. However, the incidence of catastrophic shunt failure requiring acute intervention decreased (43% versus 17%)., Conclusion: In our experience with ETV for OHC, prior CSF shunting in patients with obstructive hydrocephalus was associated with the decreased time to treatment failure following conversion to ETV. ETV may be less effective for the treatment of OHC in previously shunted patients. ETV combined with concurrent CSF shunting may be an important strategy to prevent catastrophic treatment failure in OHC patients with a history of multiple shunt revisions and complications.

Object: The majority of shunt infections occur within 6 months of shunt placement and chiefly result from perioperative colonization of shunt components by skin flora. Antibiotic-impregnated shunt (AIS) systems have been designed to prevent such colonization. In this study, the authors evaluate the incidence of shunt infection after introduction of an AIS system in a population of children with hydrocephalus., Methods: The authors retrospectively reviewed all pediatric patients who had undergone cerebrospinal fluid (CSF) shunt insertion at their institution over a 3-year period between April 2001 and March 2004. During the 18 months prior to October 2002, all CSF shunts included standard, nonimpregnated catheters. During the 18 months after October 2002, all CSF shunts included antibiotic-impregnated catheters. All patients were followed up for 6 months after shunt surgery, and all shunt-related complications, including shunt infection, were evaluated. The independent association of AIS catheter use with subsequent shunt infection was assessed via multivariate proportional hazards regression analysis. A total of 211 pediatric patients underwent 353 shunt placement procedures. In the 18 months prior to October 2002, 208 (59%) shunts were placed with nonimpregnated catheters; 145 (41%) shunts were placed with AIS catheters in the 18 months after October 2002. Of patients with nonimpregnated catheters, 25 (12%) experienced shunt infection, whereas only two patients (1.4%) with antibiotic-impregnated catheters experienced shunt infection within the 6-month follow-up period (p < 0.01). Adjusting for intercohort differences via multivariate analysis, AIS catheters were independently associated with a 2.4-fold decreased likelihood of shunt infection., Conclusions: The AIS catheter significantly reduced incidence of CSF shunt infection in children with hydrocephalus during the early postoperative period (< 6 months). The AIS system used is an effective instrument to prevent perioperative colonization of CSF shunt components.

Objective: To evaluate neurocognitive changes and predict neurocognitive outcome after ventriculoperitoneal shunting for idiopathic normal pressure hydrocephalus (INPH)., Background: Reports of neurocognitive response to shunting have been variable and studies that predict cognitive outcomes after shunting are limited. We reviewed our experience with cognitive outcomes for INPH patients who were selected for shunting based on abnormal cerebrospinal fluid (CSF) pressure monitoring and positive response in any of the NPH symptoms following large volume CSF drainage., Methods: Forty-two INPH patients underwent neurocognitive testing and Folstein Mini-Mental State Examination (MMSE) prior to shunting. Neurocognitive testing or MMSEwere performed at least 3 months after shunt insertion. Significant improvement in a neurocognitive subtest was defined as improvement by one standard deviation (1 SD) for the patient's age, sex and education level. Significant improvement in overall neurocognitive outcome was defined as a 4-point improvement in MMSE or improvement by 1 SD in 50% of the administered neurocognitive subtests. Nonparametric tests were used to assess changes. Predictors of outcome were assessed via logistic regression analysis., Results: Twenty-two patients (52.3%) showed overall neurocognitive improvement, and significant improvement was seen in tests of verbal memory and psychomotor speed. Predictive analysis showed that patients scoring more than 1 SD below mean at baseline on verbal memory immediate recall were fourfold less likely to show overall cognitive improvement, and sixfold less likely if also associated with visuoconstructional deficit or executive dysfunction. Verbal memory scores at baseline were higher in patients who showed overall cognitive improvement., Conclusions: Shunting INPH patients on the basis of CSF pressure monitoring and drainage response shows a significant rate of cognitive improvement, and baseline neurocognitive test scores may distinguish patients likely to respond to shunt surgery from those who will not., (Copyright (c) 2005 S. Karger AG, Basel.)

Introduction: Cerebrospinal fluid (CSF) shunting effectively reverses symptoms of idiopathic intracranial hypertension (IIH). Lumboperitoneal (LP) shunts have traditionally been used in patients with IIH due to a frequently undersized ventricular system. However, the advent of image-guided stereotaxis has enabled effective ventricular catheter placement in patients with IIH. We describe the first large series of frameless stereotactic ventriculoperitoneal (VP) shunting for patients with slit ventricles and IIH., Methods: We describe the frameless stereotactic VP shunting technique for IIH in 32 procedures. Outcomes following shunt placement, time to shunt failure, and etiology of shunt failure are reported., Results: A total of 21 patients underwent 32 ventricular shunting procedures (20 VP, 10 ventriculoatrial, 2 ventriculopleural). One hundred percent of shunts were successfully placed into slit ventricles, all requiring only one pass of the catheter under stereotactic guidance to achieve the desired location and CSF flow. There were no procedure-related complications and each ventricular catheter showed rapid egress of CSF. All (100%) patients experienced significant improvement of headache immediately after shunting. Ten percent of ventricular shunts failed at 3 months after insertion, 20% failed by 6 months, 50% failed by 12 months, and 60% failed by 24 months. Shunt revision was due to distal obstruction in 67%, overdrainage in 20%, and distal catheter migration or CSF leak in 6.5%. There were no shunt revisions due to proximal catheter obstruction or shunt infection., Conclusions: In our experience treating patients with IIH, frameless stereotactic ventricular CSF shunts were extremely effective at treating IIH-associated intractable headache, and continued to provide relief in nearly half of patients 2 years after shunting without many of the shunt-related complications that are seen with LP shunts. Placing ventricular shunts using image-guided stereotaxis in patients with IIH despite the absence of ventriculomegaly is an effective, safe treatment option.

Background: Innovations in shunt technology and neuroendoscopy have been increasingly applied to shunt management. However, the relative life span of shunts and the etiology of shunt failure have not been characterized recently., Methods: We reviewed the records of all shunting procedures at our institution between January 1992 and December 1998. Independent predictors of shunt failure were analyzed via multivariate Cox regression analysis in 836 shunting procedures. Independent predictors of the etiology of failure (infection, proximal obstruction, distal malfunction) were analyzed via multivariate logistic regression analysis in the 383 shunts which failed., Results: A total of 353 pediatric patients underwent 308 shunt placements and 528 revisions. The risk (hazard ratio; HR) of shunt failure decreased as a function of time in both primary placements and revised shunts. In failed shunts, the odds of infection decreased 4-fold per year of shunt function, while the odds of distal malfunction increased 1.45-fold per year. Increasing number of shunt revisions (HR 1.31, p < 0.05), decreasing patient age in years (HR 1.04, p < 0.001), gestational age <40 weeks (HR 2.15, p < 0.001) but not the etiology of hydrocephalus were associated with an increased risk of shunt failure. Revisions versus primary placements, Dandy-Walker cysts and gestational age <40 weeks were independently associated with proximal, distal and infectious causes of failure, respectively., Conclusions: The long-term shunt revision rates observed here are similar to those reported over the past 2 decades. Shunt life span remains poorer in shunt revisions and in younger patients. Patient characteristics may suggest a specific risk and mechanism of failure, aiding in the long-term management of shunted hydrocephalus., (Copyright 2002 S. Karger AG, Basel)