Ventriculoperitoneal Shunt Failure and Cerebrospinal Fluid Protein: A Meta-Analysis and Systematic Review

Ventriculoperitoneal shunts (VPS) are used to manage hydrocephalus but suffer from high failure rates. Our objectives were to (1) conduct a meta-analysis to objectively weigh this conflicting evidence, and (2) conduct a systematic review compiling and synthesizing what is known about the association between CSF proteins and shunt failure. A literature search was performed in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Embase, PubMed, and CENTRAL databases were searched from inception to June 2023. The articles were screened based on the inclusion criteria. A meta-analysis was conducted using R statistical software (R Foundation for Statistical Computing, Vienna, Austria); heterogeneity, subgroup, sensitivity, risk of bias, and publication bias analyses were performed. Thirty-one studies were selected for the systematic review, of which eight were selected for the meta-analysis. Perioperative CSF protein level was compared between 351 shunt failures and 1,094 shunt survivals; the mean difference of 24.37 mg/dL favoring shunt failure was significant (95% confidence interval=2.44-46.29 mg/dL). Our systematic review yielded a hypothesized pathogenesis: proteins attached to imperfections in the shunt surface lead to secondary attachment of cells, particularly astrocytes, and tertiary attachment of ependymal cells and the choroid plexus. Owing to the limitations of this meta-analysis, including lack of robustness due to missing data, heterogeneity, and certainty of the evidence, future research is needed to better understand the relationship between perioperative CSF protein levels and shunt failure.