Related Experiment Video
Updated: Jun 1, 2025
Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus
Published on: October 14, 2022
The utility of routine intraoperative CSF during ventricular shunt insertion: a 10-year retrospective cohort study
Michael J Stuart1,2, Annabelle M Harbison1, Timothy Ruder2
11Department of Neurosurgery, Queensland Children's Hospital, Brisbane; and.
Insights
Routine intraoperative cerebrospinal fluid (CSF) sampling during ventricular shunt insertion may not be necessary for all pediatric patients. Elevated CSF protein levels, however, are linked to increased shunt failure risk.
Area of Science:
- Pediatric Neurosurgery
- Cerebrospinal Fluid (CSF) Analysis
- Medical Resource Management
Background:
- Ventricular shunt insertion is a common pediatric neurosurgical procedure.
- The clinical utility of intraoperative CSF sampling during shunt insertion is not well-established.
- Existing research on CSF parameters predicting shunt dysfunction is limited and shows mixed results.
Purpose of the Study:
- To evaluate the clinical utility of intraoperative CSF sampling during ventricular shunt insertion.
- To determine the association between routine intraoperative CSF sample parameters and shunt failure or infection.
Main Methods:
- Retrospective review of a 10-year prospectively maintained surgical database from an Australian quaternary pediatric neurosurgical center.
- Analysis of statewide electronic medical records for demographics, shunt outcomes, and CSF biochemistry.
- Inclusion of patients undergoing new ventricular shunt insertion; exclusion of shunt revisions.
Main Results:
- Of 427 new shunt placements, 377 (88%) had routine CSF sampling.
- Common shunt failure causes included obstruction (29%), infection (17%), and valve blockage (13%).
- Elevated CSF protein levels (>300 mg/L) were significantly associated with reduced time to shunt failure (AUC 0.625).
Conclusions:
- Routine intraoperative CSF sampling may be considered for omission in pediatric patients without existing intracranial hardware.
- Elevated CSF protein levels demonstrate a dose-dependent association with increased shunt failure risk.
Objective:
Ventricular shunt insertion is a common procedure in pediatric neurosurgical practice. In many areas of medicine there is a push toward rationalization of healthcare resources and a reduction in low-value tests or procedures. The intraoperative sampling of CSF at the time of shunt insertion is one traditional aspect of care that has not been rigorously evaluated. Additionally, the role of CSF cell counts and chemistry in predicting shunt dysfunction is often discussed but poorly studied. A recent meta-analysis found a correlation between elevated CSF protein levels and shunt failure in patients with tuberculous meningitis, but not other pathologies, which limits the generalizability of those findings to Western populations. The aims of this study were to assess the clinical utility of intraoperative CSF sampling during insertion of ventricular shunts and to describe any association of routine intraoperative CSF sample parameters with shunt failure or infection.
Methods:
A retrospective review of a prospectively maintained surgical database covering 10 years of consecutive cases from a quaternary Australian pediatric neurosurgical center serving a population of 5.3 million was conducted. Statewide electronic medical records were reviewed to collate data on demographics, postoperative imaging, CSF biochemistry, instances of shunt failure, shunt revisions, and mortality. Patients undergoing insertion of a new ventricular shunt were included, while all cases of shunt revision were excluded.
Results:
During the study period, 1485 shunt procedures were performed, of which 427 involved the placement of a new ventriculoperitoneal shunt system. The mean patient age was 5.2 years (range premature-18 years). Of the 427 cases, 377 (88%) underwent routine CSF sampling. The most common indications for shunt revision were proximal catheter obstruction (51/173, 29%), followed by infection (29/173, 17%) and valve blockage (23/173, 13%). During the study period, 3 patients with existing intracranial hardware had overt ventriculitis identified at the time of intraoperative sampling, resulting in shunt removal. One patient with an existing ventricular reservoir had a delayed clinically significant infection identified on intraoperative cultures. Elevated CSF protein levels were associated with shunt failure during follow-up (area under the curve 0.625). The identified cutoff of 300 mg/L was significantly associated with a reduced time to shunt failure in both univariate and multivariate analyses.
Conclusions:
It may be reasonable to consider omission of routine intraoperative CSF sampling at the time of shunt insertion in patients without existing intracranial hardware. Elevated CSF protein levels are associated with a reduced time to shunt failure in a dose-dependent manner.
