title: Effect of electromagnetic-navigated shunt placement on failure rates: a prospective multicenter study.
abstract: OBJECTIVE
  As many as 40% of shunts fail in the first year, mainly due to proximal obstruction. The role of catheter position on failure rates has not been clearly demonstrated. The authors conducted a prospective cohort study of navigated shunt placement compared with standard blind shunt placement at 3 European centers to assess the effect on shunt failure rates.
  
  
  METHODS
  All adult and pediatric patients undergoing de novo ventriculoperitoneal shunt placement were included (patients with slit ventricles were excluded). The first cohort underwent standard shunt placement using anatomical landmarks. All centers subsequently adopted electromagnetic (EM) navigation for routine shunt placements, forming the second cohort. Catheter position was graded on postoperative CT in both groups using a 3-point scale developed for this study: (1) optimal position free-floating in CSF; (2) touching choroid or ventricular wall; or (3) intraparenchymal. Episodes and type of shunt revision were recorded. Early shunt failure was defined as that occurring within 30 days of surgery. Patients with shunts were followed-up for 12 months in the standard group, for a median of 6 months in the EM-navigated group, or until shunt failure.
  
  
  RESULTS
  A total of 75 patients were included in the study, 41 with standard shunts and 34 with EM-navigated shunts. Seventy-four percent of navigated shunts were Grade 1 compared with 37% of the standard shunts (p=0.001, chi-square test). There were no Grade 3 placements in the navigated group, but 8 in the standard group, and 75% of these failed. Early shunt failure occurred in 9 patients in the standard group and in 2 in the navigated group, reducing the early revision rate from 22 to 5.9% (p=0.048, Fisher exact test). Early shunt failures were due to proximal obstruction in 78% of standard shunts (7 of 9) and in 50% of EM-navigated shunts (1 of 2).
  
  
  CONCLUSIONS
  Noninvasive EM image guidance in shunt surgery reduces poor shunt placement, resulting in a significant decrease in the early shunt revision rate.
authors.affiliation: Department of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Lower Lane, Fazakerley, Liverpool, UK. carolinehayhurst@hotmail.com
authors.forename: Caroline
authors.initials: C
authors.lastname: Hayhurst
authors.forename: Tjemme
authors.initials: T
authors.lastname: Beems
authors.forename: Michael D
authors.initials: MD
authors.lastname: Jenkinson
authors.forename: Patricia
authors.initials: P
authors.lastname: Byrne
authors.forename: Simon
authors.initials: S
authors.lastname: Clark
authors.forename: Jothy
authors.initials: J
authors.lastname: Kandasamy
authors.forename: John
authors.initials: J
authors.lastname: Goodden
authors.forename: Rishi D S
authors.initials: RD
authors.lastname: Nandoe Tewarie
authors.forename: Conor L
authors.initials: CL
authors.lastname: Mallucci
mesh_terms: D000328:Adult; D002648:Child; D055590:Electromagnetic Phenomena; D004868:Equipment Failure; D006801:Humans; D006849:Hydrocephalus / Q000601:surgery*; D007231:Infant, Newborn; D038361:Neuronavigation; D011446:Prospective Studies; D013238:Stereotaxic Techniques; D017211:Treatment Failure; D017287:Ventriculoperitoneal Shunt / Q000009:adverse effects*