title: Using a 2-variable method in radionuclide shuntography to predict shunt patency.
abstract: OBJECTIVE
  Radionuclide shuntography interpretation is uncertain when the tracer fails to enter the ventricles but quickly drains distally or when the tracer enters the ventricles but takes longer than 15 minutes to drain distally. The purpose of this study was to aid in the clinical interpretation of a variety of shuntography results and to determine the applicability of shuntography in different patient populations.
  
  
  METHODS
  The results of 259 shuntograms were reviewed. Chi-square analysis was performed to evaluate the relationship between clinical variables and shuntography results. Two-by-two binary classification analyses were performed to determine the sensitivity, specificity, positive predictive value, and negative predictive value for 4 different combinatorial types of shuntography results based on 2 variables: ventricular tracer entry and distal tracer drainage.
  
  
  RESULTS
  Median patient age was 19 years, and 51% of patients were male. The most common presentation in patients undergoing shuntography was headache (169/254, 66.5%) with radiographically stable ventricle size. Of 227 patients with available imaging data, 163 (71.8%) presented with the same ventricle size as shown on a previous asymptomatic scan, 43 (18.9%) had larger ventricles, and 21 (9.2%) had smaller ventricles. Within 30 days of shuntography, 74 of 259 patients (28.6%) underwent surgical shunt exploration: 65 were found to have an obstructed shunt and 9 were found to have a patent shunt. Of those patients not undergoing surgery, the median length of benign clinical follow-up was 1051 days. Clinical variables were not significantly associated with shuntography results, including valve type (p = 0.180), ventricle size (p = 0.556), age (p = 0.549), distal drainage site (p = 0.098), and hydrocephalus etiology (p = 0.937). Shuntography results of patients with myelomeningocele were not dissociable from those of the group as a whole. Sensitivity to diagnose shunt failure was lowest (37.5%) but specificity was highest (97.2%) when the definition of a "normal" shuntogram included any tracer movement into the distal site within 45 minutes. Conversely, sensitivity was highest (87.5%) and specificity was lowest (51.4%) when the definition was limited exclusively to tracer entry into the ventricles and distal drainage within 15 minutes.
  
  
  CONCLUSIONS
  Even with a stringent definition of a "normal" shuntogram, sensitivity and specificity were relatively low for a diagnostic test. Clinical variables such as valve type, ventricle size, patient age, distal drainage site, and etiology of hydrocephalus were not associated with shuntography results.
authors.affiliation: Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada; and.
authors.forename: Eric M
authors.initials: EM
authors.lastname: Thompson
authors.forename: Kate
authors.initials: K
authors.lastname: Wagner
authors.forename: Kassi
authors.initials: K
authors.lastname: Kronfeld
authors.forename: Nathan R
authors.initials: NR
authors.lastname: Selden
mesh_terms: D000293:Adolescent; D000328:Adult; D002552:Cerebral Ventricles / Q000000981:diagnostic imaging* / Q000601:surgery; D002557:Cerebrospinal Fluid Shunts / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000000981:diagnostic imaging* / Q000209:etiology / Q000601:surgery*; D008297:Male; D011237:Predictive Value of Tests; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D016284:Technetium Tc 99m Pentetate; D055815:Young Adult
chemical_list: D019275:Radiopharmaceuticals; D016284:Technetium Tc 99m Pentetate
keywords: NPV = negative predictive value; OHSU = Oregon Health & Science University; PPV = positive predictive value; hydrocephalus; radionuclide shuntogram; sensitivity; shunt obstruction; specificity