Risk factors for shunt malfunction in pediatric hydrocephalus: a multicenter prospective cohort study
Risk factors for shunt malfunction in pediatric hydrocephalus: a multicenter prospective cohort study
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DOI：
10.3171/2015.6.peds14670
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发表时间：
2016-04-01
影响因子：
1.9
通讯作者：
Simon, Tamara D.
中科院分区：
文献类型：
--
作者：
Riva-Cambrin, Jay;Kestle, John R. W.;Simon, Tamara D.
目的脑脊液分流管失败率仍然高得令人无法接受。脑积水临床研究网络（HCRN）对脑积水治疗进行了全面的前瞻性观察性研究，目的是分离导致分流管失效的具体危险因素。方法：该研究跟踪了6个HCRN中心所有19岁以下儿童的首次分流插入。HCRN研究者委员会先验地选择了21个变量进行检查，包括临床、放射学和分流设计变量。分流管失败被定义为分流管翻修、随后的内镜下第三脑室造口术或分流管感染。然后使用多变量Cox比例风险模型对重要的先验定义风险因素以及在单变量分析中显著的风险因素进行独立性检验。结果：2008年4月至2011年12月，共有1036名儿童接受了首次脑脊液分流术安置。其中，344例患者出现分流管衰竭，包括265例故障和79例感染。整个队列的平均随访时间和中位随访时间分别为400天和264天。Cox模型发现，首次放置分流器时年龄小于6个月（HR 1.6 [95% CI 1.1-2.1]）、心脏合并症（HR 1.4 [95% CI 1.0-2.1]）和内镜放置（HR 1.9 [95% CI 1.2-2.9]）与分流器存活率降低独立相关。以下因素与分流生存无独立关联：病因、支付者、中心、瓣膜设计、瓣膜可编程性、超声或立体定向引导的使用、外科医生经验和容积。结论：这是报道的针对脑脊液分流治疗脑积水的儿童的最大的前瞻性研究。它证实了年龄小和使用内窥镜是第一次分流失败的危险因素，瓣膜类型没有影响。一个新的危险因素，即现有的心脏合并症也与分流衰竭有关。
OBJECTIVE The rate of CSF shunt failure remains unacceptably high. The Hydrocephalus Clinical Research Network (HCRN) conducted a comprehensive prospective observational study of hydrocephalus management, the aim of which was to isolate specific risk factors for shunt failure.METHODS The study followed all first-time shunt insertions in children younger than 19 years at 6 HCRN centers. The HCRN Investigator Committee selected, a priori, 21 variables to be examined, including clinical, radiographic, and shunt design variables. Shunt failure was defined as shunt revision, subsequent endoscopic third ventriculostomy, or shunt infection. Important a priori defined risk factors as well as those significant in univariate analyses were then tested for independence using multivariate Cox proportional hazard modeling.RESULTS A total of 1036 children underwent initial CSF shunt placement between April 2008 and December 2011. Of these, 344 patients experienced shunt failure, including 265 malfunctions and 79 infections. The mean and median length of follow-up for the entire cohort was 400 days and 264 days, respectively. The Cox model found that age younger than 6 months at first shunt placement (HR 1.6 [95% CI 1.1-2.1]), a cardiac comorbidity (HR 1.4 [95% CI 1.0-2.1]), and endoscopic placement (HR 1.9 [95% CI 1.2-2.9]) were independently associated with reduced shunt survival. The following had no independent associations with shunt survival: etiology, payer, center, valve design, valve programmability, the use of ultrasound or stereotactic guidance, and surgeon experience and volume.CONCLUSIONS This is the largest prospective study reported on children with CSF shunts for hydrocephalus. It confirms that a young age and the use of the endoscope are risk factors for first shunt failure and that valve type has no impact. A new risk factor an existing cardiac comorbidity was also associated with shunt failure.