title: Risk factors for shunt malfunction in pediatric hydrocephalus: a multicenter prospective cohort study.
abstract: OBJECT The rate of CSF shunt failure remains unacceptably high. The Hydrocephalus Clinical Research Network (HCRN) conducted a comprehensive prospective observational study of hydrocephalus management, the aim of which was to isolate specific risk factors for shunt failure. METHODS The study followed all first-time shunt insertions in children younger than 19 years at 6 HCRN centers. The HCRN Investigator Committee selected, a priori, 21 variables to be examined, including clinical, radiographic, and shunt design variables. Shunt failure was defined as shunt revision, subsequent endoscopic third ventriculostomy, or shunt infection. Important a priori-defined risk factors as well as those significant in univariate analyses were then tested for independence using multivariate Cox proportional hazard modeling. RESULTS A total of 1036 children underwent initial CSF shunt placement between April 2008 and December 2011. Of these, 344 patients experienced shunt failure, including 265 malfunctions and 79 infections. The mean and median length of follow-up for the entire cohort was 400 days and 264 days, respectively. The Cox model found that age younger than 6 months at first shunt placement (HR 1.6 [95% CI 1.1-2.1]), a cardiac comorbidity (HR 1.4 [95% CI 1.0-2.1]), and endoscopic placement (HR 1.9 [95% CI 1.2-2.9]) were independently associated with reduced shunt survival. The following had no independent associations with shunt survival: etiology, payer, center, valve design, valve programmability, the use of ultrasound or stereotactic guidance, and surgeon experience and volume. CONCLUSIONS This is the largest prospective study reported on children with CSF shunts for hydrocephalus. It confirms that a young age and the use of the endoscope are risk factors for first shunt failure and that valve type has no impact. A new risk factor-an existing cardiac comorbidity-was also associated with shunt failure.
authors.affiliation: Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah;
authors.forename: Jay
authors.initials: J
authors.lastname: Riva-Cambrin
authors.affiliation: Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah;
authors.forename: John R W
authors.initials: JR
authors.lastname: Kestle
authors.affiliation: Department of Pediatrics, University of Utah, Salt Lake City, Utah.
authors.forename: Richard
authors.initials: R
authors.lastname: Holubkov
authors.affiliation: Department of Pediatrics, University of Utah, Salt Lake City, Utah.
authors.forename: Jerry
authors.initials: J
authors.lastname: Butler
authors.affiliation: Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada;
authors.forename: Abhaya V
authors.initials: AV
authors.lastname: Kulkarni
authors.affiliation: Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada;
authors.forename: James
authors.initials: J
authors.lastname: Drake
authors.affiliation: Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas;
authors.forename: William E
authors.initials: WE
authors.lastname: Whitehead
authors.affiliation: Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee;
authors.forename: John C
authors.initials: JC
authors.lastname: Wellons
authors.affiliation: Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee;
authors.forename: Chevis N
authors.initials: CN
authors.lastname: Shannon
authors.affiliation: Division of Pediatric Neurosurgery, University of Pittsburgh, Pennsylvania;
authors.forename: Mandeep S
authors.initials: MS
authors.lastname: Tamber
authors.affiliation: Division of Pediatric Neurosurgery, Washington University, St. Louis, Missouri;
authors.forename: David D
authors.initials: DD
authors.lastname: Limbrick
authors.affiliation: Section of Pediatric Neurosurgery, Children's Hospital of Alabama, Division of Neurosurgery, University of Alabama-Birmingham, Alabama; and 
authors.forename: Curtis
authors.initials: C
authors.lastname: Rozzelle
authors.affiliation: Departments of 9 Neurosurgery and.
authors.forename: Samuel R
authors.initials: SR
authors.lastname: Browd
authors.affiliation: Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington.
authors.forename: Tamara D
authors.initials: TD
authors.lastname: Simon
mesh_terms: D000293:Adolescent; D000367:Age Factors; D002557:Cerebrospinal Fluid Shunts / Q000009:adverse effects* / Q000706:statistics & numerical data; D002648:Child; D002675:Child, Preschool; D015897:Comorbidity; D004724:Endoscopy; D004868:Equipment Failure / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006331:Heart Diseases / Q000453:epidemiology; D006801:Humans; D006849:Hydrocephalus / Q000453:epidemiology / Q000601:surgery*; D007223:Infant; D008297:Male; D017063:Outcome Assessment, Health Care; D016016:Proportional Hazards Models; D012307:Risk Factors
keywords: AIC = antibiotic-impregnated catheter; CCC = complex chronic conditions; CSF shunt; DCC = data coordinating center; FOHR = frontal and occipital horn ratio; HCRN = Hydrocephalus Clinical Research Network; Hydrocephalus Clinical Research Network; IRB = institutional review board; IVH = intraventricular hemorrhage; hydrocephalus; pediatric; prospective; risk factors