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Contrast-enhanced shunt series (“shuntography”) compare favorably to other shunt imaging modalities in detecting shunt occlusion

  • Clinical Article - Neurosurgical Techniques
  • Published:
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Abstract

Background

Obstruction is a common cause of ventriculo-peritoneal shunt failure. Head computed tomography and plain x-ray examinations of shunt tubing (“shunt series”) are routinely used in patients readmitted for reemerging symptoms but are of limited value. The validity of shunt series can be improved by applying contrast agent into the system (contrast-enhanced shunt series, a.k.a. a “shuntogram” or “shuntography”). We hypothesized that contrast-enhanced shunt series have a high predictive value for shunt revision surgeries.

Methods

We retrospectively re-evaluated 107 contrast-enhanced shunt series and reviewed the patient histories. We defined outcome parameters for calculating the utility of a pathological contrast-enhanced shunt series in predicting revision surgery.

Results

Of 107 contrast-enhanced shunt series, 41 examinations were positive for obstruction, mainly of the ventricular (36.5 %) and the peritoneal catheter (48.8 %). Within 30 days, 35 successful revision surgeries and 3 revision surgeries without resolution of symptoms were performed. In two cases the shunt tubing was found to be patent. Sixty-six negative examinations resulted in two revision surgeries, in addition to ten surgeries not attempting to restore patency. After 30 days, the specificity of contrast-enhanced shunt series for shunt failure identification was calculated at 92.8 %, the sensitivity at 94.7 %, the positive predictive value at 87.8 %, and the negative predictive value at 97.0 %.

Conclusions

The contrast-enhanced shunt series method is a highly specific examination with a negative predictive value exceeding that of head computed tomography and plain shunt series. Compared to radionuclide marker studies, contrast-enhanced shunt series demonstrate better spatiotemporal resolution, enabling focused local surgical repair.

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Abbreviations

CSF:

cerebrospinal fluid

HCP:

hydrocephalus

HCT:

head computed tomography

NPH:

normal pressure hydrocephalus

PACS:

picture archive and communication system

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Authors and Affiliations

  1. Departments of Neurosurgery, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, 37070, Göttingen, Germany

    Kajetan L. von Eckardstein, Bawarjan Schatlo, Veit Rohde, Hans Christoph Ludwig & Hans Christoph Bock

  2. Departments of Neuroradiology, Universitätsmedizin Göttingen, Göttingen, Germany

    Kai Kallenberg & Marios-Nikos Psychogios

Authors
  1. Kajetan L. von Eckardstein
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  2. Kai Kallenberg
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  3. Marios-Nikos Psychogios
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  4. Bawarjan Schatlo
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  5. Veit Rohde
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  6. Hans Christoph Ludwig
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  7. Hans Christoph Bock
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Corresponding author

Correspondence to Kajetan L. von Eckardstein.

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Funding

No funding was received for this research.

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements) or non-financial interest (such as personal or professional relationships, affiliations, knowledge or belief) in the subject matter or materials discussed in this manuscript.

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For this type of study formal consent is not required.

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Comments

Shunting dysfunctions represent very challenging issues in neurosurgery because of the heterogeneity of patients and hardware. Neurosurgeons are often required to solve life-treating situations at the last minute, frequently without the necessary information. However, the matter is underrepresented in the contemporary literature. Alternative methods, like injection of radionuclide markers or MRI or x-ray examinations, are penalized by low predictive values. In this context, the presented manuscript is welcome in order to present the authors’ results using an easy, cheap, and efficient method to identify the cause of shunting dysfunction, the so-called shuntography.

The authors retrospectively evaluated 133 contrast-enhanced shunt series over a 6.5-year time period. The study presents the typical heterogeneity of these patients: different pathologies, different shunts and valve types, and different age groups. Nevertheless, the authors performed a very exemplary analysis of the data resulting in four cases with false -egative and nine case of false-positive results; moreover, one patient experienced an allergic reaction in all probability caused by iopamidol, off-label for contrast-enhanced shunt series.

Very valuable are the three described pitfalls, the no-return valve in the prechamber, the risk of damaging the valve through forceful injection of the contrast agent, and the latency-mimicking risk.

In conclusion, the authors recommend performing contrast-enhanced shunt series instead of radionuclide tracer series, which reflects our clinical experience too. Overall, the authors should be congratulated for this straightforward study.

Lehel Török Neuruppin

Alex Alfieri Neuruppin

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von Eckardstein, K.L., Kallenberg, K., Psychogios, MN. et al. Contrast-enhanced shunt series (“shuntography”) compare favorably to other shunt imaging modalities in detecting shunt occlusion. Acta Neurochir 159, 63–70 (2017). https://doi.org/10.1007/s00701-016-3007-x

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  • DOI: https://doi.org/10.1007/s00701-016-3007-x

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