SHUNTS

Kemel Ahmed Ghotme Ghotme and James M. Drake
Hospital for Sick Children, University of Toronto
Toronto, Canada

Keywords

Hydrocephalus, CSF, shunts, ventriculoperitoneal shunt, ventriculopleural shunt, ventriculoatrial shunt, lumboperitoneal shunt, shunt selection, ventricular insertion, peritoneal insertion, complications, shunt infection, shunt occlusion, disconnection and fracture, migration, misplacement, kinking, subcutaneous effusion, overdrainage, slit ventricle syndrome, subdural collection, loculated ventricles, alternatives to shunt, craniosynostosis, postoperative care, follow-up.

1. Overview

Cerebrospinal fluid (CSF) shunts are the most common and worldwide available treatment for hydrocephalus. Before they became available, almost 50 years ago, hydrocephalus used to be a lethal or a severely disabling condition. Currently, shunts are a very common neurosurgical procedure, especially in pediatric centers, and have improved survival and quality of life for many patients with hydrocephalus all around the world. Notwithstanding, shunts frequently are related to a high rate of complications and need for re-intervention. Shunt malfunction is a frequent cause of consultation in emergency service. Opportune diagnosis and appropriate and timely treatment are crucial to prevent permanent damage or mortality in patients with hydrocephalus.

2. Types of Shunts

2.1. Definitive CSF shunts

2.2. Temporary CSF shunts

2.3. Other CSF shunts (not commonly used)

3. Shunt Components

4. The Decision to Treat

5. Planning the Procedure

6. Shunt Selection

At this time, there is no shunt system or device that has been scientifically proven to be superior to any other (1). Careful assessment of patient’s condition should be made to precisely determine the need of a shunt insertion, since this is a procedure that might be permanent and is not free of complications (See part 9). It is always important to take into account:

7.Surgical Technique

7.1. Surgical preparation and sterile protocol

7.2. Selection of a site for burr hole placement

Table I: Key points for burr hole placement

7.3. Ventricular catheter placement

7.4. Peritoneal entry

7.5. Subcutaneous dissection and tunneling

7.6. Connection of devices

7.7. Confirmation of patency

7.8. Closure

8. Post-Operative Care

9. Complications: Diagnosis and Treatment

A probability of occurrence of shunt malfunction of 81% at 12 years of follow-up has been reported in multicentric studies (4). Complications of shunts may have clinical, psychological, and economical consequences.

9.1 Infections

9.2 Mechanical complications

9.3 Overdrainage

9.4 Complications related to specific types of shunts

9.5 Other complications

10. Follow-Up

References

  1. Drake JM, Saint-Rose C: The Shunt Book. Blackwell Science, Cambridge, MA, 1995.
  2. Whitehead WE, Jea A, Vachhrajani S, Kulkarni A, Drake J: Accurate placement of cerebrospinal fluid shunt ventricular catheters with real-time ultrasound guidance in older children without patent fontanelles. Technical note. J Neurosurg: Pediatr 107;406-410, 2007.
  3. Frim DM, Gupta N: Chapter 14. Pediatric Neurosurgery. Landes Bioscience, Georgetown, TX, 2006.
  4. Saint-Rose C, Piatt JH, Renier D, Pierre-Kahn A, Hirsch JF, Hoffman HJ, Humphreys RP, Hendrick EB: Mechanical complications in shunts. Pediatr Neurosurg 17:2-9, 1991-1992.
  5. Ghotme K, Drake J, Lamberti-Pasculli M, Rutka J: Management of Shunt Disconnections and Fractures in Children: Experience at the Hospital for Sick Children. Unpublished data, presented at the 2007 AANS Pediatric Section Meeting, South Beach, Fl.