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.

[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.

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.

Late shunt infection: incidence, pathogenesis, and therapeutic implications

Shunt infections (SI) are a major concern in pediatric neurosurgery. Although SI occurs generally shortly after surgery, it can be very delayed in a number of cases. The incidence of late shunt infection (LSI) is not established, and the sources of contamination are poorly understood. We reviewed 1,793 pediatric cases from our database, with a mean follow-up of 9.12 years. We selected 40 cases of SI occurring more than one year after the previous shunt operation. These represented 12.7 % of SI, and the annual incidence of LSI was 0.28 % in our series. Peritonitis, generally due to appendicitis, was the cause of LSI in 11 cases. Hematogenous contamination was diagnosed in eight cases, because the germ was Haemophilus,Pneumococcus, or Listeria, or an ENT infection had preceded SI; the incidence of purulent meningitis was significantly higher in shunted patients than in the general population. LSI was due in seven cases to bowel perforation, and in four to direct inoculation, after abdominal surgery or traumatic exposure of the shunt. In the remaining 10 cases, no potential cause of infection was identified, and persistence of a germ since the previous shunt operation was suspected. SI represents a life-long threat after shunting, and may be unrelated to shunt surgery.

Neonatal ventriculosubgaleal shunts

OBJECTIVE

We report on 32 neonates treated with ventriculosubgaleal (VSG) shunts to determine VSG shunt survival and associated complications.

METHODS

Between 1993 and 1997, 37 VSG shunts were placed in 32 neonates when the cerebrospinal fluid (CSF) or the abdomen was considered unsuitable for ventriculoperitoneal shunt placement. In each child, a ventricular catheter was attached to 3 cm of a closed-end peritoneal tube via a right-angle connector, which drained into a surgically created subgaleal pocket.

RESULTS

The causes of hydrocephalus were as follows: intraventricular hemorrhage (IVH) in 20 neonates, meningitis/ventriculitis in 6, IVH and infection in 2, and other causes in 4. The mean postconception age at the time of VSG shunt insertion was 37.2 weeks (33.1 wk in the IVH group), and the mean weight was 2227 g (1724 g in the IVH group). The average preoperative head circumference was 33.6 cm. The average survival of these 37 VSG shunts (five children had two VSG shunts) was 35.1 days. The complications were as follows: one CSF leakage occurred when sutures were removed; one catheter fell into the ventricle and required removal, and one child died immediately after VSG shunt revision. There were no VSG shunt infections. All surviving children followed for a minimum of 4 months after insertion of a VSG shunt (n = 24) have required a ventriculoperitoneal shunt. Mean follow-up from the time of first VSG shunt insertion was 21.6 months. Four children died as a result of causes unrelated to the VSG shunt.

CONCLUSION

VSG shunts offer a simple, effective, and relatively safe means of temporizing hydrocephalus, and they avoid the need for external drainage or frequent CSF aspiration in these medically unstable infants until the CSF characteristics and abdomen are acceptable for ventriculoperitoneal shunting.

Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus

OBJECT

Repeated cerebrospinal fluid (CSF) shunt failures in pediatric patients are common, and they are a significant cause of morbidity and, occasionally, of death. To date, the risk factors for repeated failure have not been established. By performing survival analysis for repeated events, the authors examined the effects of patient characteristics, shunt hardware, and surgical details in a large cohort of patients.

METHODS

During a 10-year period all pediatric patients with hydrocephalus requiring CSF diversion procedures were included in a prospective single-institution observational study. Patient characteristics were defined as age, gender, weight, head circumference, American Society of Anesthesiology class, and cause of hydrocephalus. Surgical details included whether the procedure was performed on an emergency or nonemergency basis, use of antibiotic agents, concurrent surgical procedures, and duration of the surgical procedure. Details on shunt hardware included: the type of shunt, the valve system, whether the shunt system included multiple or complex components, the type of distal catheter, the site of the shunt, and the side on which the shunt was placed. Repeated shunt failures were assessed using multivariable time-to-event analysis (by using the Cox regression model). Conditional models (as established by Prentice, et al.) were formulated for gap times (that is, times between successive shunt failures). There were 1183 shunt failures in 839 patients. Failure time from the first shunt procedure was an important predictor for the second and third episodes of failure, thus establishing an association between the times to failure within individual patients. An age younger than 40 weeks gestation at the time of the first shunt implantation carried a hazard ratio (HR) of 2.49 (95% confidence interval [CI] 1.68-3.68) for the first failure, which remained high for subsequent episodes of failure. An age from 40 weeks gestation to 1 year (at the time of the initial surgery) also proved to be an important predictor of first shunt malfunctions (HR 1.77, 95% CI 1.29-2.44). The cause of hydrocephalus was significantly associated with the risk of initial failure and, to a lesser extent, later failures. Concurrent other surgical procedures were associated with an increased risk of failure.

CONCLUSIONS

The patient's age at the time of initial shunt placement and the time interval since previous surgical revision are important predictors of repeated shunt failures in the multivariable model. Even after adjusting for age at first shunt insertion as well as the cause of hydrocephalus, there is significant association between repeated failure times for individual patients.

Outcome data and analysis in pediatric neurosurgery

OBJECTIVE

The purpose of this study was to analyze the outcomes of five commonly performed pediatric neurosurgical operations: 1) initial shunt insertion; 2) first shunt revision; 3) craniotomy for brain tumor; 4) correction of sagittal synostosis; and 5) release of tethered cords. A second purpose was to analyze the neurological outcome data after tethered cord releases.

METHODS

Morbidity and mortality records, patient charts, and operative records were reviewed to determine length of hospitalization and, for each disorder, the pertinent outcomes such as duration of shunt function and incidence of infection or neurological morbidity.

RESULTS

Many outcome data were expected, such as a high long-term shunt function rate after primary shunt insertion (65% at 5 yr), a low mortality rate (1%) and permanent morbidity rate (10%) after craniotomy for brain tumor, and a low frequency of transfusion (20%) for sagittal synostosis operations. The outcomes among the three neurosurgeons varied more than expected, e.g., the duration of hospitalization after sagittal reconstructions ranged from 3.1 to 5.8 days; the frequency of infections of primary shunt revisions ranged from 0 to 15%; and the neurological morbidity after tethered cord releases ranged from 0 to 12%, with all neurological morbidity occurring in patients undergoing their second or third tether release.

CONCLUSION

The data may serve as a basis for outcome comparisons for these procedures. Outcome data allow us to analyze factors to improve patient care, but outcome analysis is complex.

[Clinical experience with the Sp[hy adjustable valve in the treatment of adult hydrocephalus. A series of 147 cases]

OBJECTIVE

Evaluate the advantages, results and drawbacks of the Sophy adjustable valve (SV) in the treatment of hydrocephalus in the adult.

MATERIAL AND METHODS

One-hundred and forty-seven adult hydrocephalic patients (mean age = 64.5 years) shunted with a SV between 1990 and 1997 were retrospectively reviewed. Etiologies of hydrocephalus were: "normal pressure" chronic hydrocephalus (NPH) in 124 and tumoral hydrocephalus with intracranial hypertension in 23 patients. One-hundred fifty shunts were established in 147 patients: 14 ventriculoatrial and 136 ventriculoperitoneal shunts. The initial pressure settings of the SV were: high pressure: 12 times (8%), medium pressure: 136 times (90.6%) and low pressure: 2 times (1.3%).

RESULTS

Sixteen patients were lost to follow-up. Two patients died within hours following the procedure. So, the results were analyzed in the 129 remaining patients, with a follow-up of 16.7 months (+/- 17.8). Three patients died from shunted-related causes (2.3%). Eighty-four patients had good results (65%), 25 had fair results (19.5%) and 20 failed to improve or deteriorated (15.5%) after shunting. Fifty-three reoperations were performed in 44 patients (34%), including 37 procedures for mechanical obstruction and 6 for septic complications. Subdural effusions (SDE) occurred in 16 patients (12.5%): 10 surgical evacuations were required in 7 patients; 8 patients were successfully treated using uprating of the SV pressure alone; one was managed conservatively. Fifty-eight pressure readjustments were performed in 47 patients. The pressure settings were uprated 28 times in patients showing clinical or computerized tomographic (CT) features suggesting overdrainage; 20 of those proved to be successful (71.5%). The pressure settings were lowered 30 times in patients showing a lack of improvement after shunting, attributed to underdrainage; only 12 of those proved to be successful (40%). Spontaneous changes of the pressure settings were observed in 14 patients (10.8%). After a MRI exposure, SV pressure changes were observed in 64% of patients.

DISCUSSION

The technological refinements that have been proposed to eliminate the overdrainage which occurs in most usual cerebrospinal fluid shunts are reviewed. The SV valve has allowed non-invasive adjustments of its opening pressure in patients showing complications ascribed to inappropriate drainage. The need for additional surgery was eliminated in 20% to 25% of patients of the present series. Because of frequent spontaneous and magnetic resonance-induced pressure changes, the need for repeated controls of valve pressure is to be reemphasized.

CONCLUSION

This experience suggests that the SV represents a substantial improvement over standard fixed-pressure valves.

Cerebrospinal fluid shunt infections in infants and children in Mobile, Alabama

Cerebrospinal fluid shunt systems are used to treat hydrocephalus in infants and children; unfortunately, some shunt systems become infected. We sought to define the epidemiology of shunt infections and shunt survival prior to infection at our institution. We identified 268 shunt procedures performed from January 1990 to June 1996 in 145 patients. There were 29 episodes of shunt infection for an incidence of 10.8% per procedure and 13.1% per patient. Staphylococcus epidermidis was the most common isolate recovered. The probability of shunt infection was highest during the first 8 weeks after a shunt procedure and subsequent infection was less likely after 28 weeks.

Functioning periods and complications of 246 cerebrospinal fluid shunting procedures in 208 children

To investigate the functioning periods and the causes of cerebrospinal fluid shunt failures, 246 shunts inserted in 208 children from October 1985 to August 1992 at the authors' institute were retrospectively reviewed. The mean age at shunt insertion was 4.0 years and the reasons for the shunting procedures were congenital hydrocephalus (47.6% per procedure), tumor-associated hydrocephalus (21.1%), postmeningitic hydrocephalus (11.8%), congenital cyst (10.6%) and others (8.9%). All except 2 were shunted to the peritoneal cavity. Forty-five operations for shunt failure were done (18.3%) during the follow-up period (mean, 32 months). The functioning (shunt survival) rates at 6, 12, 24 and 36 months after surgery were 91.6%, 86.6%, 83.6% and 82.9%, respectively. The complications were mechanical malfunction (12.2%), infection (4.1%), subdural fluid collection which required drainage (1.6%) and migration (0.4%). About half of the mechanical malfunctions and infections which had occurred during the follow-up period were within 6 months and 2 months after surgery, respectively. There was no shunt-related mortality. These chronological data should be considered in the planning of follow-up schedules.

Complications with shunts in adults with spina bifida

OBJECTIVE

To assess the incidence of malfunction of shunts in adults with spina bifida who have shunts to control hydrocephalus.

DESIGN

A retrospective review of the medical notes and contact by questionnaire of adults with spina bifida to assess symptoms, function of shunts, frequency of operative procedures, and follow-up.

SUBJECTS

110 patients with shunts who attended Lord Mayor Treloar College for the physically disabled between 1978 and 1993.

RESULTS

The average (range) number of revisions of shunts per person was 3.6 (0-28). Although 37 patients underwent an emergency operation for revision in their first year of life, there was a continuing low incidence, increasing in the early teenage years, which persisted into the third decade. Intervals between emergency revisions varied: 202/320 occurred within one year of the last shunt operation, 56 occurred after five years, 24 after 10 years, and 15 after 15 or more years. Fifteen patients had chronic intermittent headaches, of whom four died and three suffered severe morbidity. Thirteen died; three had raised intracranial pressure, and four died suddenly; these deaths were presumed to be related to their shunts. Up to the age of 16 there was 100% hospital follow up, but after that only 40% of young adults underwent review, including review of their shunt function.

CONCLUSION

Shunts to control hydrocephalus may fail after many years without symptoms. This is difficult to diagnose and if missed may lead to chronic morbidity and death. As hospital follow up of this group is falling, both general practitioners and hospital doctors must be aware that a shunt may malfunction after prolonged quiescent periods.

Current prognosis in fetal ventriculomegaly

A review of 51 cases referred for evaluation of fetal ventriculomegaly revealed adequate follow-up data in 40 patients. Three of the fetuses were electively aborted and 37 were delivered. There were no cases of death in utero. Of the 37 infants who were delivered, 26 (70%) were treated with shunt placement for neonatal hydrocephalus. The reasons for nontreatment included: inaccurate diagnosis, resolution of hydrocephalus by the time of delivery, neonatal death, and parental wishes. Survival time in the 26 shunt-treated patients ranged from 5 days to 14 years (average 4.25 years); five of these patients died within the first 2 weeks of life. Among the 26 treated patients, satisfactory cognitive ability was found in 10 (38%). Of the seven surviving nontreated infants, satisfactory cognitive ability was demonstrated in six (86%). Children with myelomeningocele displayed cognitive development similar to that in patients without myelomeningocele. The findings suggest that, of patients with in utero diagnosis of ventriculomegaly, approximately one-half survive (4-year average follow-up interval) and 38% of the survivors treated with shunt insertion have normal cognitive development. No subgroup likely to benefit from in utero treatment of ventriculomegaly was identified. Associated central nervous system or systemic malformations were identified in 26 (70%) of the 37 who came to delivery. This community-acquired series, not collected from a high-risk obstetrical-perinatal service, may reflect the general experience of the neurosurgeon consulting in such cases.

Fatal cardiopulmonary complications in children treated with ventriculoatrial shunts

During the years from 1965 to 1986, 716 children underwent a total of 2065 shunt procedures in our department. Of these, 1298 were ventriculoatrial (VA). Until 1979, Pudenz VA shunts were almost exclusively used as the primary procedure as well as in revisions. Since 1980, mini-Holter VA shunts have been implanted as a second choice, usually in cases with repeated distal failure in ventriculoperitoneal (VP) shunts. Observation time for children with VA shunts is therefore from 10 to 23 years for the great majority. The cumulative death rate for all patients is 24% (175/716), 9% (64/716) being tumor patients who eventually died as a result of their neoplasm. Most of the other deaths were caused by shunt infection or occurred in a group of children where shunts had been implanted for palliative reasons and where follow-up was only sporadic. Among the 450 children with VA shunts, 15 fatal complications occurred that were directly related to the atrial catheter, resulting in an accumulated incidence of 3% of such serious side effects from VA shunting. Three of these 15 fatal cases presented with nonspecific signs of cardiopulmonary failure following 10-21 years' shunting, and they died from irreversible pulmonary hypertension within a few months. A fourth case of late cor pulmonale has done unexpectedly well and has improved considerably while receiving anticoagulant therapy for over a period of 3 years.

Sudden death in hydrocephalic spina bifida aperta patients

Twelve patients of 146 hydrocephalic spina bifida aperta patients, treated with a ventricular drainage system, died suddenly. In 7 of them the cause of death was most probably related to the use of a ventriculovascular shunt, causing pulmonary embolism. Thromboembolic complications were not seen in the 26 hydrocephalic spina bifida patients treated with a ventriculoperitoneal shunt. In 4 other patients shunt malfunction was considered as the cause of sudden death. The case reports of these 11 patients are presented. Pathophysiological mechanisms are discussed and measures for prevention of these two potentially lethal complications are described.

Ventriculocholecystic shunt. A mortality report

Ventriculocholecystic shunts are not commonly used for the treatment of hydrocephalus. We present a case of a child who underwent such a procedure and died of unusual complications. This case represents a unique juxtaposition of uncommon neurosurgical entities and complications including acquired communicating hydrocephalus, bilious ventriculitis secondary to a ventriculocholecystic shunt, and pulmonary edema. The unusual features of this case are discussed and emphasis is placed on the pathophysiologic findings.

[Surgical treatment of hydrocephalus in children. I. Clinical development and mortality]

The authors analized the clinical evolution and the mortality of fifty seven children with hydrocephalus due to congenital malformation (41.1%), meningitis (36.8%) and tumors (21.1%), that were submitted to surgical treatment for hydrocephalus, from 1970 to 1980. Insertions of ventriculostomy reservoir and of external ventricular drainage were satisfactory used to control the expanding hydrocephalus in children with meningitis, that wait insertion of the valve. The use of hypothalamic ventriculostomy with catheter has showed satisfactory results in the treatment of children with hydrocephalus due to non inflammatory origin. Ventriculoatrial shunts were utilized in few cases but were useful in the treatment of hydrocephalus in children. The operative mortality rate was 25.7%. Ventriculoperitoneal shunts showed good results in the treatment of hydrocephalus in 89.4% of the cases in the immediate post-operative time and this number drop to 88.2% at the eighteen post-operative month. The overall mortality rate was 34%. At the end of the third post-operative month 27.3% of the survivors of the children with hydrocephalus due to congenital malformation and meningitis submitted to ventriculoperitoneal shunts showed normal neuromotor development and at the end of the second post-operative year this number increased to 50%. The operative mortality rate in this group was 25% and the majority of death occurred due to meningitis.

Complications of ventriculoatrial and ventriculoperitoneal shunts in a new children's hospital

At a new children's hospital between 1974 and 1978, 125 patients underwent 243 shunt procedures performed by six neurosurgeons. In spite of diverse techniques used, the overall results were acceptable. Seventy-seven patients required 118 shunt revisions. The mortality related to the shunt procedures of 7.2% and the infection rate of 14.4% were comparable to those of other series reported during the same period. Ventriculoatrial shunts, although fewer in number, required fewer revisions (20 revisions of 18 shunts) than ventriculoperitoneal shunts (97 revisions of 58 shunts) for which the variation in technique was larger. A sharp decline in the complication rate was noted during the last year of the study.

Long-term results after ventriculoatrial and ventriculoperitoneal shunting for infantile hydrocephalus

This series of 228 patients with infantile non-neoplastic hydrocephalus who received either a ventriculoatrial (VA) or a ventriculoperitoneal (VP) shunt before 2 years of age was followed for an average of 7 years, and the results with the two types of shunt were compared. Mortality and infection rates were similar for both groups of patients, but children with VP shunts required significantly fewer revisions and had a much greater likelihood of not having any revisions during the follow-up period. Late complications occurred more frequently with VA shunts and were more serious. It is concluded that VP shunts offer significant advantages over VA systems in this population.

Extracranial CSF shunting for infantile non tumoral hydrocephalus--a retrospective analysis of 360 cases

A series of 360 consecutive extracranial CSF shunts performed between June 1960 and June 1976 for infantile non tumoral hydrocephalus is reviewed. The surgical methods used, the reasons for re-operation, the time distribution of post-operative complications, the causes of death and the long term results are analysed and discussed for each of the four groups: tetraventricular communicating hydrocephalus, triventricular hydrocephalus, obstructive hydrocephalus with a ventriculo-cisternal block and post-meningocele or post-myelomeningocele hydrocephalus.

The surgical risk in the treatment of Arnold Chiari malformations

The authors describe a series of 26 patients (28 operations) with Arnold Chiari malformations who were admitted during a 4 year period. In 20 the malformation was treated by direct surgery on the posterior fossa. Seven were treated by ventriculoatrial shunting. An analysis of the surgical risks of each procedure is given. In addition a helpful guide in the choice of the proper surgical procedure is outlined.

Follow-up analysis of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus

The authors report an analysis of 300 patients in whom primary treatment for hydrocephalus was either a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt. Although differences in primary and total revision rates between placements were not statistically significant, the VA shunt failures carried a higher morbidity than the VP placements.

[Comparative study of complications observed in ventriculo-atrial and ventriculo-peritoneal derivations. Apropos of 106 cases]

In this study that concerns 106 cases, authors insist on the frequency of the infectious and mechanical complications. They make a review of the etiologies and of the various materials used by themselves and study successively the mechanical, infectious and mixed complications, sector by sector. They drive, at each level, conclusions concerning the results with their subsequent lessons. Having recalled, in short, the principles of supervision of any child bearer of a "valve", they conclude by developing their present idea of the "ideal derivation" by on the base of the material submitted to experimentation. They insist on the value of the ventricular-peritoneal derivations in the new-born.

Follow-up comparison of hydrocephalus with and without myelomeningocele

A series of 454 hydrocephalic patients with and without myelomeningocele and with and without treatment is reviewed. The survival rates for hydrocephalus alone and for hydrocephalus with myelodysplasia are comparable. The authors reach the conclusion that treatment of the hycrocephalic process and its complications is the most critical therapeutic consideration. Mental retardation is the major unalterable cause for failure to develop independence; some lesser emotional causes can be modified by encouragement. Repeated reassessment of the patient's condition and adjustment are important. Before treatment is started parents or guardians should be fully informed of the child's future potential for independent life and mental development.

Primary ventriculo-peritoneal shunts in treatment of hydrocephalus associated with myelomeningocele

In 50 children suffering from open myelomeningocele, a ventriculo-peritoneal shunt was employed as the primary procedure for control of hydrocephalus. In 11 cases the system was ultimately replaced by a ventriculo-atrial shunt, though this may not always have been necessary. In the remaining 39 patients satisfactory control of hydrocephalus was achieved. Obstruction, particularly of the peritoneal catheter, occurred frequently in the first 6 months but no revisions were required after 2 years. It is concluded that while ventriculo-peritoneal and ventriculo-atrial shunts achieve comparable success in controlling hydrocephalus, the former, due to the relatively innocuous complications, offers significant long-term advantages.

Complications from Holter ventriculo-atrial shunts

Three hundred and thirty cases of infantile hydrocephalus were treated at the Westminster Children's Hospital over a 6-year period with the Holter ventrculo-atrial shunt. The complications of the treatment are studied and methods of management discussed.

A technique for the insertion of Holter ventriculoatrial shunt for infantile hydrocephalus

A technique for the insertion of the Holter ventriculo-atrial shunt for the treatment of infantile hydrocephalus and the pre- and postoperative management of such patients is described.

The technique has been applied to 330 hydrocephalic children with minimal operative mortality and with a greatly reduced incidence of morbidity over previous methods. Simplification of the original method is considered an important factor in the satisfactory results.

The technique can be carried out in a general hospital without special equipment and by a surgeon with paediatric surgical experience but without special neurosurgical training.