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      Shunt infusion studies: impact on patient outcome, including health economics

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          Abstract

          Objectives

          The diagnosis of shunt malfunction is often not straightforward. We have explored, in symptomatic shunted patients with hydrocephalus or pseudotumour cerebri syndrome (PTCS), the accuracy of CSF infusion tests in differentiating a functioning shunt from one with possible problems, and the health economic consequences.

          Methods

          Participants: hydrocephalus/PTCS patients with infusion tests performed from January 2013 until December 2015. We followed patients up after 6 and 12 months from the test to determine whether they had improved, had persisting symptoms or had required urgent revision. We calculated the total cost savings of revision versus infusion tests and standard protocol of revision and ICP monitoring versus infusion tests.

          Results

          Three hundred sixty-five shunt infusion tests had been performed where a shunt prechamber/reservoir was present. For hydrocephalus patients, more than half of the tests (~ 55%, 155 out of 280) showed no shunt malfunction versus 125 with possible malfunction (ages 4 months to 90 years old). For PTCS patients aged 10 to 77 years old, 47 had possible problems and 38 no indication for shunt malfunction. Overall, > 290 unnecessary revisions were avoided over 3 years’ time. Two hundred fifty-eight (> 85%) of those non-surgically managed, remained well, did not deteriorate and did not require surgery. No infections were associated with infusion studies. For Cambridge, the overall savings from avoiding revisions was £945,415 annually.

          Conclusions

          Our results provide evidence of the importance of shunt testing in vivo to confirm shunt malfunction. Avoiding unnecessary shunt revisions carries a strong health benefit for patients that also translates to a significant financial benefit for the National Health Service and potentially for other healthcare systems worldwide.

          Electronic supplementary material

          The online version of this article (10.1007/s00701-020-04212-0) contains supplementary material, which is available to authorized users.

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          Most cited references31

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          Monitoring and interpretation of intracranial pressure.

          Derek J. Pickard, M Czosnyka (2004)
          Intracranial pressure (ICP) is derived from cerebral blood and cerebrospinal fluid (CSF) circulatory dynamics and can be affected in the course of many diseases of the central nervous system. Monitoring of ICP requires an invasive transducer, although some attempts have been made to measure it non-invasively. Because of its dynamic nature, instant CSF pressure measurement using the height of a fluid column via lumbar puncture may be misleading. An averaging over 30 minutes should be the minimum, with a period of overnight monitoring in conscious patients providing the optimal standard. Computer-aided recording with online waveform analysis of ICP is very helpful. Although there is no "Class I" evidence, ICP monitoring is useful, if not essential, in head injury, poor grade subarachnoid haemorrhage, stroke, intracerebral haematoma, meningitis, acute liver failure, hydrocephalus, benign intracranial hypertension, craniosynostosis etc. Information which can be derived from ICP and its waveforms includes cerebral perfusion pressure (CPP), regulation of cerebral blood flow and volume, CSF absorption capacity, brain compensatory reserve, and content of vasogenic events. Some of these parameters allow prediction of prognosis of survival following head injury and optimisation of "CPP-guided therapy". In hydrocephalus CSF dynamic tests aid diagnosis and subsequent monitoring of shunt function.
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            CSF hydrodynamic studies in man. 2 . Normal hydrodynamic variables related to CSF pressure and flow.

            J Ekstedt (1978)
            With the patient in the supine position, the subarachnoidal space was infused with artificial CSF at several constant pressure levels. The resulting flow of liquid was recorded. By draining CSF at a low pressure the CSF production rate was determined. Normal values are given and discussed for (1) the resting pressure, (2) the conductance of the CSF outflow pathways, (3) the formation rate of CSF, (4) the pressure difference across the CSF outflow pathways, and (5) the sagittal sinus pressure. None of the variables showed any age dependence, nor was there any sex difference.
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              Cerebrospinal fluid dynamics.

              John D. Pickard, Shahan Momjian, Zofia H Czosnyka … (2004)
              Hydrocephalus is far more complicated than a simple disorder of CSF circulation. Historically, it has been diagnosed using clinical and psychomotor assessment plus brain imaging. The role of physiological measurement to aid diagnosis becomes more appreciated in current clinical practice. This has been reflected by recently formulated guidelines for the management of normal pressure hydrocephalus. Clinical measurement in hydrocephalus is mainly related to intracranial pressure (ICP) and cerebral blood flow. This review lists and discusses most common forms of the methods: CSF infusion study, overnight ICP monitoring, assessment of slow ICP waves, testing pressure reactivity, cerebral autoregulation, CO2 reactivity and PET-CBF studies combined with MRI co-registration. The basics of CSF dynamics modelling are presented and the principles of the assessment of functioning of the implanted hydrocephalus shunts are also discussed. The descriptions of multiple forms of measurement along with clinical illustrations are mainly based on in-house experience of a multidisciplinary group of scientists and clinicians from Cambridge, UK.
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                Author and article information

                Contributors
                Afroditi-Despina Lalou:
                ORCID: http://orcid.org/0000-0003-3768-8681
                adl43@cam.ac.uk
                Journal
                Journal ID (nlm-ta): Acta Neurochir (Wien)
                Journal ID (iso-abbrev): Acta Neurochir (Wien)
                Title: Acta Neurochirurgica
                Publisher: Springer Vienna (Vienna )
                ISSN (Print): 0001-6268
                ISSN (Electronic): 0942-0940
                Publication date (Electronic): 20 February 2020
                Publication date PMC-release: 20 February 2020
                Publication date (Print): 2020
                Volume: 162
                Issue: 5
                Pages: 1019-1031
                Affiliations
                [1 ]GRID grid.24029.3d, ISNI 0000 0004 0383 8386, Department of Clinical Neurosciences, Division of Neurosurgery, , Cambridge University Hospital NHS Foundation Trust, ; Cambridge, UK
                [2 ]Department of Neurosurgery, Ospedale S.M. Goretti, Latina, Italy
                Author information
                http://orcid.org/0000-0003-3768-8681
                Article
                Publisher ID: 4212
                DOI: 10.1007/s00701-020-04212-0
                PMC ID: 7156359
                PubMed ID: 32078047
                SO-VID: c4d97f0f-da82-47bd-b469-82caba848f2a
                Copyright © © The Author(s) 2020
                License:

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                Date received : 5 October 2019
                Date accepted : 6 January 2020
                Funding
                Funded by: University of Cambridge
                Categories
                Subject: Original Article - CSF Circulation
                Custom metadata
                issue-copyright-statement © Springer-Verlag GmbH Austria, part of Springer Nature 2020

                ScienceOpen disciplines: Surgery
                Keywords: cerebrospinal fluid diversion,hydrocephalus,idiopathic intracranial hypertension,infusion studies,pseudotumour cerebri,shunts,shunt testing in vivo
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: cerebrospinal fluid diversion, hydrocephalus, idiopathic intracranial hypertension, infusion studies, pseudotumour cerebri, shunts, shunt testing in vivo

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