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Low-pressure valves in hydrocephalic children: a retrospective analysis
G. E. Breimer
D. A. Sival
E. W. Hoving
0
) Department of Neurosurgery, University Hospital Groningen (UMCG)
, Hanzeplein 1, P.O. Box 30 001, 9700 RB Groningen,
The Netherlands
Purpose A series of 100 children under 2 years of age treated for hydrocephalus is described. All patients received a standard differential low-pressure (SD low) valve as the first cerebrospinal fluid (CSF) shunt treatment. The performance of this group during follow-up is analysed. Methods A retrospective cohort study was performed using the intern electronic health record from our hospital. Children younger than 2 years who underwent initial CSF shunt treatment with a SD low valve between 1998 and 2008 were eligible. Results Mean follow-up was 7 years. The majority of 81% (81 of 100) of the children did not receive an upgrade of pressure profile throughout follow-up. The first revision was done after a mean of 456 days (median, 64 days; min, 3; and max, 4,183). The 1-year survival rate of the CSF shunt in this cohort was 42%. In the relatively large group of myelomeningocele patients (37 of 100), only one patient developed symptomatic overdrainage. A total of 9% (9 of 100) of the children presented with symptoms of overdrainage. In 3% (3 out of 100) of these children, symptoms of overdrainage persisted, in spite of multiple valve mutations. During the total follow-up, 26% (26 of 100) of the patients had never received shunt revision surgery. Fifteen percent (15 of 100) of the children developed a shunt infection within the first year. Conclusions The use of SD low valves in the youngest age group is effective in the majority of children. The aetiology of myelomeningocele appears to protect the patient from symptomatic overdrainage.
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Hydrocephalus can be defined as an active distension of the
ventricular system of the brain resulting from inadequate
passage of cerebrospinal fluid (CSF) from its point of
production within the cerebral ventricles to its point of
absorption into the systemic circulation (i.e. triventricular and
communicating hydrocephalus respectively) [11]. The
former is often related to an obstruction between the third and
fourth ventricles while the latter does not show any
morphological obstructions. The aetiology of hydrocephalus
varies, and a MRI scan is important to define its cause.
The overall incidence of infantile hydrocephalus is about
0.66 per 1,000 live births [8].
The most common treatment for the hydrocephalus in
infants is the insertion of a CSF shunt. The alternative
treatment of endoscopic third ventriculostomy (ETV) in
cases of triventricular hydrocephalus is controversial in this
youngest age group [3]. Therefore, CSF shunt insertion is
considered standard treatment especially in young children.
The adverse effects of CSF shunts are well recognized, and
a shunt dysfunction is a common problem in neurosurgery.
Many different types of shunts have been designed to
overcome these problems, but the ideal shunt still does not exist.
The shunt trial has shown that different types of valves show
comparable outcomes [4, 6]. The number of different valves
has been increasing ever since, but basically, these valves
can be distinguished according to the differential pressure
gradients: low, medium and high. In young children, there is
no consensus about the best pressure gradient for valves.
We describe a series of children (n 0100) who all
received a standard differential low-pressure (SD low) valve
as first shunt treatment. This treatment policy is based on the
hypothesis that as long as the sutures of the skull have not
closed, the intracranial pressure will be low.
The overall characteristics of this cohort are analysed
concerning aetiology and shunt survival rates. A more
detailed analysis is presented of a subcategory of patients with
serious overdrainage problems. The potential relationship
between symptomatic overdrainage and the implantation of
SD low valves is analysed and discussed.
The present retrospective study was approved by the
Medical Ethical Committee of University Hospital Groningen
(UMCG), the Netherlands. After informed consent of the
parents, we investigated a retrospective cohort of children
under the age of 2 years who primary received a CSF shunt
with a SD low valve. All patients were treated within the
period from 1998 to 2008, at UMCG. A total of 112 patients
were treated with a CSF shunt during the period of
inclusion. The initial treatment of 12 patients was with a SD
medium-pressure valve; these were excluded from this
study. Mean follow-up was 7 years.
Children from northern parts of the Netherlands are
referred to our clinic. The total population of this area is about
1.7 million. All procedures were performed by a
neurosurgeon or resident under supervision of a neurosurgeon.
The standard treatment of hydrocephalus in this young
age group has been CSF shunt implantation using a SD low
valve (PS Medical Low). This valve has an opening pressure
of 5 cm CSF without an ant (...truncated)