Commentary on:
Failed Ventriculoperitoneal Shunt: Is
Retrograde Ventriculosinus Shunt
a Reliable Option?
by Oliveira et al. World Neurosurg 92:445-453, 2016

Management of Challenging Hydrocephalus Scenarios: Clinical Perspective
Samer K. Elbabaa1 and Pablo Gonzalez-Lopez2

T he cerebrospinal fluid (CSF) shunt remains as the most
common treatment choice for nonobstructive hydro-
cephalus worldwide. The morbidity and mortality related
to shunt malfunctions and infections continue to carry heavy
clinical and economical tolls on patients, families, and health care
lateral ventricle into the superior sagittal sinus. The intravenous
portion of the catheter was inserted against the direction of blood
flow within the superior sagittal sinus, using the impact pressure
at the tip of the catheter to make the stabilized intracranial
pressure (ICP) higher than the venous pressure. Theoretically,
systems. Shunts are considered as life-saving devices but are this will avoid overdrainage secondary to posture or changes in
notorious for high failure rates. The neurosurgical literature is rich the intrathoracic pressure.4-6
with many retrospective and prospective studies looking at risk
factors for shunt malfunction, as well as new and improved ways For more than 50 years, neurosurgeons and biomedical engi-
to reduce shunt-related morbidity and mortality.1 Over the past neers invested many efforts to improve the designing of shunt
2 decades, many developments of new adjuncts, such as the hardware, although the overall concept remains unchanged
use of frameless stereotaxy, ultrasound, and antibiotic- except for a few advances. The advances are focused on con-
impregnated catheters, may explain the improvement in CSF trolling the CSF flow, as well as lowering the shunt malfunction
shunt survivals from a multicenter composite cohort (1990s) to a and infection rates. Approximately 40% of shunts fail within 2
modern 2007e2012 cohort as reported by Kulkrani et al2 in 2013. years after first implant, and more than 95% fail within 10 years.
The pediatric hydrocephalus systematic literature review and Classically, shunt obstruction is the cause of shunt malfunction.
evidence-based guidelines found insufficient evidence to The proximal ventricular catheter is obstructed in 60%, the valve
demonstrate an advantage for 1 shunt hardware design over in 30%, and the distal catheter in 10% of patients with shunt
another in the treatment of pediatric hydrocephalus.3 malfunction. There are continued efforts to reach the “smart
shunt,” a concept defined as an implantable system (hardware
In a paper recently published in WORLD NEUROSURGERY, Oliveira and algorithms) designed to control CSF drainage on the basis of
and colleagues share their experience with using the retrograde the feedback from sensors within the system (ICP, posture po-
ventriculosinus shunt (VSS) in adult patients with failed ven- sition, and CSF flow). The concept of a smart shunt can allow the
triculoperitoneal shunts (VPS). They concluded that when VPS is surgeon to access historical data such as ICP and CSF flow
not feasible, VSS is a safe second option with potential advan- patterns.1
tages such as lower risk of overdrainage and good functional
results. Their series excluded pediatric and normal pressure hy- In a recent comprehensive prospective observational study
drocephalus (NPH) patients. The VSS was implanted via the El- conducted by the Hydrocephalus Clinical Research Network
Shafei technique using a valveless shunt catheter from the aiming to isolate specific risk factors for shunt failure in pediatric

Key words Abbreviations and Acronyms From the 1Division of Pediatric Neurosurgery, Department of Neurological Surgery, St. Louis
- Failed ventriculoperitoneal shunt CSF: Cerebrospinal fluid University School of Medicine, St. Louis, Missouri, USA; and 2Department of Neurosurgery,
- Hydrocephalus ETV: Endoscopic third Neurooncology and Skull Base Unit, Miguel Hernandez University Hospital General
- Neurosurgery ventriculostomy Universitario de Alicante, Alicante, Spain
- Retrograde ventriculosinus shunt ICP: Intracranial pressure To whom correspondence should be addressed: Samer K. Elbabaa, M.D.
IJV: Internal jugular vein [E-mail:]
VAS: Ventriculoatrial shunt Citation: World Neurosurg. (2016) 96:599-601.
VPS: Ventriculoperitoneal shunt
VSS: Ventriculosinus shunt


Holubkov R. Neurosurgery. after most common risks of pleural shunts include CSF shunt removal. or excessive intraoperative sinus bleeding. 2001. history of mul. shunt). Childs Nerv Syst. Butler J. Riva-Cambrin J. the arachnoid villi. case report. El Shafei IL. Verdonck P.11 tiple WORLD NEUROSURGERY. 1985. Risks of VASs include hydrocephalus (preferably due to idiopathic aqueductal stenosis) thromboembolic complications and high revision rates. J Neurosurg Pediatr. evolution. Pediatric hydrocephalus: systematic litera.53:778-779 [discus- sion: 466]. treatment of hydrocephalus by shunting the ce- alus Clinical Research Network cohort with his. there were no common complications hydrocephalus.4(suppl 1): shunting the cerebrospinal fluid to the venous S38-50. acting as priate patients. and peritoneal entry method were not of the cerebral ventricles.9 patients with shunted hydrocephalus. Pediatric Hydrocephalus Systematic 6. Ventriculovenous shunt against the multicenter prospective cohort study. Proc Inst Mech Eng H. Pediatr Neurosurg. Kestle JR. Browd SR. Butler J. Samadani U. Van Review and Evidence-Based Guidelines Task ventriculo-sinus shunt (El Shafei RVS shunt). Klimo P Jr. shunting in children: comparison of Hydroceph. Mareels G. Flannery AM. modelling of the ventriculosinus shunt (El-Shafei ture review and evidence-based guidelines. 8. especially in the ventriculostomy (ETV) in patients with a history of obstructive very young pediatric population.10 Toma et al11 carried a literature search and accommodates large volumes of CSF per day. 600 www. can have a success rate ranging from 40%! underabsorption leading to progressive pleural effusion and 100% when other ETV risk factors for failure such as shunt respiratory distress. 2016. New and 4. or suboptimal peritoneal catheter position can lead to frequent distal VPS malfunctions. Auguste KI. REFERENCES efficacy. 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