Ventricular catheter entry site and not catheter tip location predicts shunt survival: a secondary analysis of 3 large pediatric hydrocephalus studies.
OBJECTIVE Accurate placement of ventricular catheters may result in prolonged shunt survival, but the best target for the hole-bearing segment of the catheter has not been rigorously defined. The goal of the study was to define a target within the ventricle with the lowest risk of shunt failure. METHODS Five catheter placement variables (ventricular catheter tip location, ventricular catheter tip environment, relationship to choroid plexus, catheter tip holes within ventricle, and crosses midline) were defined, assessed for interobserver agreement, and evaluated for their effect on shunt survival in univariate and multivariate analyses. De-identified subjects from the Shunt Design Trial, the Endoscopic Shunt Insertion Trial, and a Hydrocephalus Clinical Research Network study on ultrasound-guided catheter placement were combined (n = 858 subjects, all first-time shunt insertions, all patients < 18 years old). The first postoperative brain imaging study was used to determine ventricular catheter placement for each of the catheter placement variables. RESULTS Ventricular catheter tip location, environment, catheter tip holes within the ventricle, and crosses midline all achieved sufficient interobserver agreement (κ > 0.60). In the univariate survival analysis, however, only ventricular catheter tip location was useful in distinguishing a target within the ventricle with a survival advantage (frontal horn; log-rank, p = 0.0015). None of the other catheter placement variables yielded a significant survival advantage unless they were compared with catheter tips completely not in the ventricle. Cox regression analysis was performed, examining ventricular catheter tip location with age, etiology, surgeon, decade of surgery, and catheter entry site (anterior vs posterior). Only age (p < 0.001) and entry site (p = 0.005) were associated with shunt survival; ventricular catheter tip location was not (p = 0.37). Anterior entry site lowered the risk of shunt failure compared with posterior entry site by approximately one-third (HR 0.65, 95% CI 0.51-0.83). CONCLUSIONS This analysis failed to identify an ideal target within the ventricle for the ventricular catheter tip. Unexpectedly, the choice of an anterior versus posterior catheter entry site was more important in determining shunt survival than the location of the ventricular catheter tip within the ventricle. Entry site may represent a modifiable risk factor for shunt failure, but, due to inherent limitations in study design and previous clinical research on entry site, a randomized controlled trial is necessary before treatment recommendations can be made.
Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.
William E
WE
Whitehead
Division of Neurosurgery, University of Calgary, Alberta, Canada.
Jay
J
Riva-Cambrin
Division of Neurosurgery, University of Toronto, Ontario, Canada.
Abhaya V
AV
Kulkarni
Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee.
John C
JC
Wellons
Department of Neurosurgery, University of Alabama at Birmingham, Alabama.
Curtis J
CJ
Rozzelle
Department of Neurosurgery, University of Pittsburgh, Pennsylvania.
Mandeep S
MS
Tamber
Department of Neurosurgery, Washington University, St. Louis, Missouri;
David D
DD
Limbrick
Departments of 8 Neurosurgery and.
Samuel R
SR
Browd
Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee.
Robert P
RP
Naftel
Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee.
Chevis N
CN
Shannon
Pediatrics, University of Washington, Seattle, Washington.
Tamara D
TD
Simon
Department of Pediatrics, University of Utah, Salt Lake City, Utah.
Richard
R
Holubkov
Department of Radiology, Baylor College of Medicine, Houston, Texas; and.
Anna
A
Illner
Division of Neurosurgery, University of Toronto, Ontario, Canada.
D Douglas
DD
Cochrane
Division of Neurosurgery, University of Toronto, Ontario, Canada.
James M
JM
Drake
Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.
Thomas G
TG
Luerssen
Department of Neurosurgery, University of Alabama at Birmingham, Alabama.
W Jerry
WJ
Oakes
Department of Neurosurgery, University of Utah, Salt Lake City, Utah.
John R W
JR
Kestle
D000367:Age Factors; D002408:Catheters, Indwelling; D002557:Cerebrospinal Fluid Shunts; D002648:Child; D002675:Child, Preschool; D004867:Equipment Design; D004868:Equipment Failure; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000601:surgery*; D007223:Infant; D007231:Infant, Newborn; D053208:Kaplan-Meier Estimate; D008297:Male; D015999:Multivariate Analysis; D019635:Neurosurgical Procedures / Q000295:instrumentation* / Q000379:methods*; D016016:Proportional Hazards Models; D025321:Surgery, Computer-Assisted / Q000379:methods; D014463:Ultrasonography / Q000379:methods
CSF shunts; ESIT = Endoscopic Shunt Insertion Trial; HCRN = Hydrocephalus Clinical Research Network; IVH = intraventricular hemorrhage; SDT = Shunt Design Trial; hydrocephalus; pediatric; shunt entry site; ventricular catheter