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Value of computerized shunt infusion study in assessment of pediatric hydrocephalus shunt function—a two center cross-sectional study

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Abstract

Background

Hydrocephalus shunt malfunction can—also in children—occur insidiously without clear symptoms of raised intracranial pressure (ICP) or changes in ventricular size, imposing a diagnostic challenge. Computerized shunt infusion studies enable quantitative shunt function assessment. We report on feasibility and results of this technique in children in a two center cross-sectional study.

Material and methods

Shunt infusion study (SIS) is performed with two needles inserted into a pre-chamber for ICP recording and CSF infusion. After baseline ICP recording, constant rate infusion is started until a new ICP plateau (ICPpl) is reached. Dedicated software containing the shunt’s resistance characteristics calculates ICP and its amplitude outflow resistance and critical shunt pressure (CSP). Overall, 203 SIS were performed in 166 children. Shunts were defined as functional if ICPpl was <CSP and obstructed if ICPpl was > 5 mmHg above CSP and borderline in between.

Results

Forty-one shunts (20.2%) were found obstructed, 26 (12.8%) had borderline characteristics, and 136 (67%) were functional. Baseline ICP in obstructed shunts was significantly above shunt operating pressure. CSF outflow resistance (Rout) and ∆ICP plateau were significantly elevated in obstructed shunts, with cut-off thresholds of 8.07 mmHg min/ml and 11.74 mmHg respectively. Subgroup analysis showed smaller ventricles in 69% of revised cases.

Conclusion

SIS is a feasible, reliable, and radiation-free technique for quantitative shunt assessment to rule out or prove shunt malfunction. Dedicated software containing shunt hydrodynamic characteristics is necessary and small children may need short-term sedation. Due to the clinical and inherent economic advantages, SIS should be more frequently used in pediatric neurosurgery.

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Abbreviations

AMP:

Fundamental amplitude (1st harmonic) of ICP after Fourier transformation

CSF:

Cerebro spinal fluid (Cerebrospinal fluid)

CSP:

Critical shunt pressure determined by software according to shunt characteristics

EI:

Evans’ index

FOHR:

Fronto-ccipital horn ratio

ICP:

Intracranial pressure

ICPpl:

ICP at plateau phase of infusion study

MRI:

Magnetic resonance imaging

opICP:

Expected intracranial pressure at the operating pressure of the shunt valve

R out :

Resistance to CSF outflow

VP-Shunt:

Ventriculo-peritoneal shunt

ΔICP (mmHg):

Difference between ICP at baseline and ICP plateau

ΔAMP (mmHg:

Difference between AMP at baseline and AMP at plateau

ΔICPop (mmHg):

Difference between theoretical operating pressure according to valve setting and ICP at baseline

ΔCSP (mmHg):

Difference between ICP at plateau and CSP

ΔR out (mmHg min/ml):

Difference between measured Rout and laboratory-tested Shunt Rout

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Acknowledgments

MC is supported by the National Institute of Health Research, Cambridge Centre.

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Author notes

  1. Sandra Fernandes Dias, Afroditi–Despina Lalou, Martin U. Schuhmann and Zofia Czosnyka contributed equally to this work.

Authors and Affiliations

  1. Division of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tübingen, 72076, Tübingen, Germany

    Sandra Fernandes Dias, Regine Spang & Martin U. Schuhmann

  2. Department of Neurosurgery, University Hospital of Zurich, 8091, Zürich, Switzerland

    Sandra Fernandes Dias

  3. Academic Neurosurgery Unit, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK

    Afroditi–Despina Lalou, Matthew Garnett, Helen Fernandez, Marek Czosnyka & Zofia Czosnyka

  4. Department of Pediatric Neurology, University Children’s Hospital Tübingen, 72076, Tübingen, Germany

    Karin Haas-Lude

  5. Institute of Electronic Systems, Warsaw University of Technology, 00-661, Warsaw, Poland

    Marek Czosnyka

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  1. Sandra Fernandes Dias
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  2. Afroditi–Despina Lalou
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Corresponding author

Correspondence to Martin U. Schuhmann.

Ethics declarations

The retrospective data collection and analysis was approved by the institutional ethics review board of Tübingen (Ref. 160/2018BO2). From Cambridge Institution, no additional ethical approval was required, as SIS is a clinical tool that has been performed after clinical request. Before intervention, parents were informed about the procedure and possible related complications (e.g., infection) and gave a consent.

Conflict of interest

MC receives part of licensing fees for the software ICM+used for data collection and analysis in this study. The other authors have no conflict of interest to report

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Dias, S.F., Lalou, A., Spang, R. et al. Value of computerized shunt infusion study in assessment of pediatric hydrocephalus shunt function—a two center cross-sectional study. Childs Nerv Syst 36, 59–71 (2020). https://doi.org/10.1007/s00381-019-04264-3

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