- Department of Surgery, The Aga Khan University, Stadium Road, Karachi, Sindh, Pakistan
- Department of Biological and Biomedical Sciences, The Aga Khan University, Stadium Road, Karachi, Sindh, Pakistan
Muhammad E. Bari
Department of Surgery, The Aga Khan University, Stadium Road, Karachi, Sindh, Pakistan
DOI:10.4103/2152-7806.151388Copyright: © 2015 Khan F. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Khan F, Rehman A, Shamim MS, Bari ME. Factors affecting ventriculoperitoneal shunt survival in adult patients. Surg Neurol Int 13-Feb-2015;6:25
How to cite this URL: Khan F, Rehman A, Shamim MS, Bari ME. Factors affecting ventriculoperitoneal shunt survival in adult patients. Surg Neurol Int 13-Feb-2015;6:25. Available from: http://sni.wpengine.com/surgicalint_articles/factors-affecting-ventriculoperitoneal-shunt-survival-in-adult-patients/
Background:Ventriculoperitoneal (VP) shunt insertion remains the mainstay of treatment for hydrocephalus despite a high rate of complications. The predictors of shunt malfunction have been studied mostly in pediatric patients. In this study, we report our 11-year experience with VP shunts in adult patients with hydrocephalus. We also assess the various factors affecting shunt survival in a developing country setting.
Methods:A retrospective chart analysis was conducted for all adult patients who had undergone shunt placement between the years 2001 and 2011. Kaplan–Meier curves were used to determine the duration from shunt placement to first malfunction and log-rank (Cox–Mantel) tests were used to determine the factors affecting shunt survival.
Results:A total of 227 patients aged 18–85 years (mean: 45.8 years) were included in the study. The top four etiologies of hydrocephalus included post-cranial surgery (23.3%), brain tumor or cyst (22.9%), normal pressure hydrocephalus (15%), and intracranial hemorrhage (13.7%). The overall incidence of shunt malfunction was 15.4% with the median time to first shunt failure being 120 days. Etiology of hydrocephalus (P = 0.030) had a significant association with the development of shunt malfunction. Early shunt failure was associated with age (P P P = 0.010), excision of brain tumors (P = 0.008), and placement of extra-ventricular drains (P = 0.033).
Conclusions:Patients with increased age, prolonged hospital stay, GCS score of less than 13, extra-ventricular drains in situ, or excision of brain tumors were more likely to experience early shunt malfunction.
Keywords: Cerebrospinal fluid shunt, hydrocephalus, ventriculoperitoneal shunt
Ventriculoperitoneal (VP) shunt placement is the mainstay of treatment for hydrocephalus in both adult and pediatric patients.[
VP shunt malfunction remains the most frequent reason for shunt revisions.[
Hereby, we report an 11-year experience of managing adult hydrocephalus, including etiologies of disease, patient demographics, shunt survival and failure rate, and causes of shunt malfunction.
We performed a retrospective chart review using our inpatient database. Files were retrieved using International Classification of Diseases, 9th Revision-Clinical Modification (ICD-9-CM) codes for “hydrocephalus” and “ventriculoperitoneal shunt.” Adult patients were defined as those who were 18 years of age or older. Each file was individually reviewed for various details such as patient demographics, presentation, neurological examination, laboratory and radiological investigations, medical and surgical management, hospital stay, follow-up, and further management. Follow-up in neurosurgery clinics was specifically reviewed for periodic shunt assessment, persistent or new onset symptoms, and any neurological deficits in terms of visual symptoms and motor and cognitive deficits. In case of shunt malfunction, cause and delay from first insertion to revision were also studied. Any and all further hospital admissions and surgeries were also studied.
Types of hydrocephalus we identified included normal pressure hydrocephalus (NPH), obstructive hydrocephalus, idiopathic hydrocephalus (etiology unknown), and communicating hydrocephalus, as previously reported by Reddy et al.[
The primary outcome of interest of this retrospective clinical study was shunt survival and revision rate. Causes of shunt failure were also determined. Shunt failure was defined as by Reddy et al.[
Data were recorded on a pre-tested proforma. Statistical procedures included frequency determination, mean and standard deviation, and Pearson's Chi-square test for comparison of proportions. The Student's t-test and independent sample t-test or the Mann–Whitney U test was used for comparison of means or medians, respectively. For all comparisons, a P < 0.05 was considered statistically significant. Kaplan–Meier curves were used to determine duration from shunt placement to first malfunction. The log-rank (Mantel–Cox) test was used to determine the factors affecting shunt survival. Data entry and statistical analysis were performed on Statistical Package for Social Sciences version 19 (IBM SPSS Statistics 19, IBM Corporation, Chicago, Illinois).
A total of 319 patients underwent VP shunt placement during the 11-year period. The total number of all types of neurosurgical procedures carried out at our center during the same time period was approximately 13,000. These VP shunt procedures were performed by seven different neurosurgeons. Pressure-controlled shunts (Medtronic) were used in all cases at a medium pressure in most cases; these shunts have a distal valve located within the pump and cost about US $240 in Pakistan.
Out of the 319 patients identified initially, 92 were excluded because of the unavailability of medical records [
Etiologies and clinical manifestations
The etiologies of hydrocephalus in our patients included post-cranial surgery (n = 53, 23.3%), brain tumor or cyst (n = 52, 22.9%), NPH (n = 34, 15%), hemorrhage (n = 31, 13.7%), tuberculous meningitis (n = 9, 4.0%), bacterial meningitis or brain abscess (n = 2, 0.9%), and others (n = 46, 20.3%). Other etiologies included shunt malfunction (n = 16, 7%), TBI (n = 13, 5.7%), post-meningitis (n = 14, 6.2%), Arnold–Chiari or Dandy–Walker malformation (n = 8, 3.5%), and idiopathic (n = 7, 3.1%), as given in
Of the 31 (13.7%) patients with intracranial hemorrhage as an etiology, 23 (10.1%) had SAH, 6 (2.6%) had intraparenchymal hemorrhage, and 2 (0.9%) had subdural hematoma. Among patients with brain tumors (n = 52, 22.9%), extra-axial tumors (n = 30, 13.2%) were more common than intra-axial tumors (n = 22, 9.7%). Meningioma or oligodendroglioma (n = 12, 5.3%), vestibular schwannoma (n = 10, 4.4%), and hemangioblastoma or hemangioma (n = 7, 3.1%) were the most common. Posterior cranial fossa (n = 16, 7.0%), cerebellopontine angle (n = 15, 6.6%) and supra- or parasellar (n = 9, 4.0%) region were the most common sites for tumors. The types of hydrocephalus were obstructive hydrocephalus (n = 155, 68.3%), NPH (n = 39, 17.2%), communicating hydrocephalus (n = 25, 11.0%), and idiopathic (n = 8, 3.5%) [
Symptoms at the time of presentation included headache (n = 101, 44.5%), drowsiness or altered consciousness (n = 91, 40.1%), gait disturbances (n = 89, 39.2%), nausea or vomiting (n = 69, 30.4%), weakness (n = 52, 22.9%), urinary or fecal incontinence (n = 44, 19.4%), decline in memory (n = 26, 11.4%), visual abnormality (n = 26, 11.4%), fever (n = 25, 11.0%), and seizures (n = 22, 9.7%). On presentation, the Glasgow Coma Scale (GCS) score of patients ranged from 3 to 15, with a mean of 12 and a median of 14. Twenty-six (11.4%) patients were comatose (GCS ≤ 8) on presentation, while GCS score was less than 13 in all patients with drowsiness (n = 91, 40.1%). Motor deficits were found in 99 (43.6%) patients. Laboratory investigations in these patients included serum chemistry, blood counts, blood culture, and radiological investigations. Lumbar puncture was performed in 116 (51.1%) patients.
Depending on the clinical condition of patients, they were managed in general ward, special care units, or intensive care units. The mean duration of hospital stay was 13.6 ± 1.1 days. One hundred and ninety-five (85.9%) of the patients received antibiotics. Mannitol was administered to 28 (12.3%) patients, while only 9 (4.0%) patients received acetazolamide. Anticonvulsants and steroids were used in 57 (25.1%) and 51 (22.5%) patients, respectively. Nine (4.0%) patients also received anti-tuberculous therapy.
Surgical management of the patients other than VP shunt placement included extra-ventricular drains (n = 43, 18.9%), craniotomy or craniectomy (n = 31, 13.7%), clipping of aneurysm (n = 12, 5.3%), ventriculostomy (n = 5, 2.2%) and other procedures. All the patients included in this study underwent VP shunt placement. Two hundred (88.1%) patients underwent VP shunt placement only once, while 27 (11.9%) patients required revision of the malfunctioned shunt later on. Of these patients, four (1.8%) required revision of the malfunctioned shunt during the same admission. A right-sided shunt was placed in 209 (92.1%) patients, while the remaining 18 (7.9%) patients received a left-sided shunt.
Only 161 (70.9%) patients followed up regularly; rest of the patients (n = 66, 29.1%) were lost to follow-up after the first postoperative clinic visit. The mean duration of follow-up was 321.6 days. Twelve (5.3%) patients died, most of whom (n = 10, 4.4%) died within a month after surgery. The remaining two patients (0.9%) died 2 months and 10 months post-surgery, respectively. Cardiac arrest (n = 3, 1.3%), brain-stem death (n = 2, 0.9%), and pulmonary embolism (n = 1, 0.4%) were the known causes of death in these patients. The exact cause of death in the remaining cases was not known.
The incidence of overall shunt malfunction was found to be 15.4%, while the incidence of shunt revision was 14.1%. Kaplan–Meier curve showed that shunt failure rates at 6 months, 1 year, and 6 years were 19/227 (8.4%), 25/227 (11.0%), and 35/227 (15.4%), respectively. The most common causes of shunt malfunction were shunt blockade (n = 25, 11.0%), shunt infection (n = 8, 3.5%), shunt migration (n = 2, 0.9%), and CSF ascites (n = 2, 0.9%) [
Factors affecting time to first shunt failure (VP shunt survival)
Overall median time from shunt placement to shunt malfunction was 120 days, ranging from 2 to 2095 days [
Patients who had a GCS score of less than 13 were found to experience early shunt failure (P = 0.010, log-rank test) as shown in
Despite the fact that CSF diversion with VP shunt placement has been the mainstay of management in both pediatric and adult hydrocephalus, VP shunts still have noteworthy complications and failure rate.[
Demographics, such as age, gender, and co-morbid conditions, did not upset the shunt function overall, but median time to shunt malfunction was severely affected by extreme of age. This might be accounted for by the fact that elderly patients have fragile and atrophic brain parenchyma. Surgical intervention in such patients was probably associated with a higher risk of iatrogenic trauma inflicted to the nearby tissues while placing the VP shunt. Injury to cells of the choroid plexus within the ventricles could lead to the accumulation of cellular debris within the catheter and clog the tubing of the VP shunt, resulting in shunt blockage.[
Among the etiologies of hydrocephalus, hemorrhage was found to have a significantly adverse impact on the functional outcome of patients, which is in line with observation from earlier studies.[
In contrast to the etiology of hydrocephalus, the type of hydrocephalus did not influence overall shunt malfunction and survival. Albeit previous studies have not found any association between clinical features and shunt survival,[
Most of the shunt failures occurred within 6 months post shunt placement, which is compatible with previous reports from developed countries.[
The VP shunt failure rate reported earlier ranged from 18% to 29% for adult hydrocephalus.[
This study has certain limitations due to its retrospective design. Results of this study could be affected by technical factors like different surgeons, and their experience and preference of surgical methods. Moreover, only those patients were included in this study whose medical records were complete and retrievable; this might have introduced selection bias. Shunt survival in patients who were excluded due to missing records remains unknown. Similarly, shunt survival analysis was performed only for those who were able to follow-up regularly. A significant proportion of patients who were either excluded due to missing data or failed to follow-up regularly may have skewed the results of our study.
Despite the aforementioned shortcomings, this study contributes substantially to the scientific pool of knowledge. This is the first study from the region to gather and analyze very detailed data of adult patients with hydrocephalus undergoing VP shunt placement. Patients’ past medical and surgical history, etiology of hydrocephalus, hospital course, and follow-up in clinics were extensively studied to find the association with shunt survival. Although this study reveals a lower shunt failure rate and a median shunt survival time that concurs with earlier studies, prospective studies focusing on periodic evaluation of shunt and functional status may shed more light on the predictors of shunt survival and long-term functional outcome.
Our study showed that patients undergoing surgical excision of tumor and patients in whom extra-ventricular drains were placed were more likely to have an early shunt failure. Altered consciousness at presentation (GCS score of less than 13) was a predictor of decreased shunt survival time. Shunt survival was also significantly affected by age and duration of hospital stay.
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