title: Use of programmable versus nonprogrammable shunts in the management of hydrocephalus secondary to aneurysmal subarachnoid hemorrhage: a retrospective study with cost-benefit analysis.
abstract: OBJECTIVE
  The choice of programmable or nonprogrammable shunts for the management of hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) remains undefined. Variable intracranial pressures make optimal management difficult. Programmable shunts have been shown to reduce problems with drainage, but at 3 times the cost of nonprogrammable shunts.
  
  
  METHODS
  All patients who underwent insertion of a ventriculoperitoneal shunt for hydrocephalus after aneurysmal SAH between 2006 and 2012 were included. Patients were divided into those in whom nonprogrammable shunts and those in whom programmable shunts were inserted. The rates of shunt revisions, the reasons for adjustments of shunt settings in patients with programmable devices, and the effectiveness of the adjustments were analyzed. A cost-benefit analysis was also conducted to determine if the overall cost for programmable shunts was more than for nonprogrammable shunts.
  
  
  RESULTS
  Ninety-four patients underwent insertion of shunts for hydrocephalus secondary to SAH. In 37 of these patients, nonprogrammable shunts were inserted, whereas in 57 programmable shunts were inserted. Four (7%) of 57 patients with programmable devices underwent shunt revision, whereas 8 (21.6%) of 37 patients with nonprogrammable shunts underwent shunt revision (p = 0.0413), and 4 of these patients had programmable shunts inserted during shunt revision. In 33 of 57 patients with programmable shunts, adjustments were made. The adjustments were for a trial of functional improvement (n = 21), overdrainage (n = 5), underdrainage (n = 6), or overly sunken skull defect (n = 1). Of these 33 patients, 24 showed neurological improvements (p = 0.012). Cost-benefit analysis showed $646.60 savings (US dollars) per patient if programmable shunts were used, because the cost of shunt revision is a lot higher than the cost of the shunt.
  
  
  CONCLUSIONS
  The rate of shunt revision is lower in patients with programmable devices, and these are therefore more cost-effective. In addition, the shunt adjustments made for patients with programmable devices also resulted in better neurological outcomes.
authors.affiliation: Department of Neurosurgery, National Neuroscience Institute, Singapore.
authors.forename: Lester
authors.initials: L
authors.lastname: Lee
authors.forename: Nicolas K K
authors.initials: NK
authors.lastname: King
authors.forename: Dinesh
authors.initials: D
authors.lastname: Kumar
authors.forename: Yew Poh
authors.initials: YP
authors.lastname: Ng
authors.forename: Jai
authors.initials: J
authors.lastname: Rao
authors.forename: Huiyu
authors.initials: H
authors.lastname: Ng
authors.forename: Kah Keow
authors.initials: KK
authors.lastname: Lee
authors.forename: Ernest
authors.initials: E
authors.lastname: Wang
authors.forename: Ivan
authors.initials: I
authors.lastname: Ng
mesh_terms: D000328:Adult; D000368:Aged; D003362:Cost-Benefit Analysis; D004867:Equipment Design; D006801:Humans; D006849:Hydrocephalus / Q000209:etiology* / Q000601:surgery*; D007902:Length of Stay; D008875:Middle Aged; D012189:Retrospective Studies; D013345:Subarachnoid Hemorrhage / Q000150:complications*; D017287:Ventriculoperitoneal Shunt / Q000191:economics* / Q000295:instrumentation
keywords: ICP = intracranial pressure; NPH = normal-pressure hydrocephalus; SAH = subarachnoid hemorrhage; SDH = subdural hemorrhage; VP = ventriculoperitoneal; cost analysis; hydrocephalus; shunt; subarachnoid hemorrhage; vascular disorders