Neurochirurgia 18 (1975), 118-120 © Georg Thieme Verlag Stuttgart
Results of the Treatment of Hydrocephalus with Ventriculo-Jugular Shunts J. W. F. Beks, M.D., C. A. ter Weeme, M.D.
Summary 260 children with hydrocephalus were treated with a ventriculo-jugular shunt. We compared the complication - rate between Holter-shunts and Pudenz-shunts. As far as we could verify 58 children died from several causes. 190 revisions were done in 114 patients, 110 revisions in 71 children with a Holter - valve and 80 revisions in 43 children with a Pudenz valve. The complication-rate was 112 in 176 Holter - valves and 84 in 84 Pudenz - systems. In our hands the use of the Holtersystem gives better results. As one can conclude from these figures and those from others (Tsingoglou and Forrest 1971), the treatment of children with hydrocephalus is still far from ideal.
avons comparé les taux de complications suivant l'utilisation des valves de Holter ou de Pudenz. Dans la mesure où nous avons pu le vérifier 58 enfants sont décédés pour plusieurs causes. 190 révisions ont été effectuées chez 114 sujets, 110 sur 71 enfants et 80 chez 43 enfants porteurs respectivement d'une valve de Holter ou de Pudenz. Les complications furent au nombre de 112 pour 176 Holter et de 84 pour 84 Pudenz. Entre nos mains le système Holter donne de meilleurs résultats. Ces chiffres, tout comme ceux d'autres auteurs (Tsingoglou et Forrest, 1971) amènent à conclure que le traitement des enfants hydrocéphales est loin d'être idéal.
Key words: hydrocephalus - shunt operation Holter valve - Pudenz valve
Although in the recent years much progress has been made in our knowledge of physiology of the cerebrospinal fluid and the diagnostic and therapeutic management of patients with disturbances of the circulation of this fluid, there are still many problems left. Widespread introduction of the ventriculojugular shunts has revolutionised the outlook for countless hydrocephalic infants and the success of this procedure is now well established. However with new methods of treatment come new diseases. There is a relative high frequency of complications and a high rate of revisions (Forrest c. s. 1968; Tischer 1969; Noble c. s. 1970; Tsingoglou 1971; Mc. Laurin 1973). The morbidity from ventriculo-jugular shunts is considered in order to form an impression of the morbidity of this kind of operation. We compared the complications of two kinds of ventriculo-jugular shunts, namely the Holter - valve and the Pudenz - system.
Zusammenfassung 260 Kinder mit Hydrocephalus wurden mit ventrikulo-jugularen Shunts behandelt. Wir verglichen die Komplikationsrate zwischen Holterund Pudenz-Systemen. So weit uns bekannt wurde, starben 58 Kinder aus verschiedenen Gründen. 190 Revisionen bei 114 Patienten wurden erforderlich, 110 Revisionen bei 71 Kindern mit Holter-Ventil und 84 bei 84 Pudenz-Systemen. In unserer Hand ergab die Verwendung von Holtersystemen bessere Ergebnisse. Wie man aus den Tabellen und den Ergebnissen anderer (Tsingoglou u. Forrest 1971) ersehen kann, ist die Behandlung von Kindern mit Hydrocephalus noch längst nicht ideal. Résumé Résultats du traitement de l'hydrocéphalie par les dérivations ventriculo-jugulaires. 260 enfants hydrocéphaliques ont été traités par une dérivation ventriculo-jugulaire. Nous
Introduction
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KNniek voor Neurochirurgie, Academisch Ziekenhuis, Groningen. The Netherlands.
Results of the Treatment of Hydrocephalus with Ventrico-Jugular Shunts
In a period from Jan. 1960 to Jan. 1973 260 hydrocephalic children were treated by ventriculo-jugular shunts in the University Clinic for Neurosurgery in Groningen. Of these patients 176 were treated, using the Holier - valve; 84 patients were treated using the Pudenz - system (table 1). These shunts were inserted in following the standard procedure. Table 1: Numbers of operated children with hydrocephalus Hoher
Pudenz total
with myelomeningocele
92
31
123
without myelomeningocele
84
53
137
176
84
260
Of these children 123 developed a hydrocephalus after closing a myelomeningocele, and in these cases primary operation was done during the first week of life.
In children in whom Holter - shunts have been inserted 11 died from meningitis, 4 by other infections, 10 from other causes and 11 unknown. In those children with a Pudenzshunt 9 died from meningitis, 8 from other causes and in 5 children the cause of death was unknown (table 3).
Table 3: Causes of death Holter meningitis
Pudenz total
11
9
20
4
0
4
other causes (tumours)
10
8
18
unknown
11
5
16
36
22
58
other infections
Revisions The of the shunt. in 114
most common indication for revision system was a dysfunctioning of the In total 190 revisions were performed children (table 4).
Mortality Of the total number of patients 58 died and of 41 we could not get further information; the remaining 161 are still alive. 36 of the patients who died, had a Holter - valve and 22 a Pudenz - Heyer apparatus (table 2).
Number of Revisions
Holter
Pudenz total
1
50
20
70
2
10
15
25
Pudenz total
3
7
5
12
Table 2: Follow-up Holter
Table 4: Frequency of operation for revision of shunts - of the 260 patients 114 required revision. Total revisions: 190
died
36
22
58
4
2
1
3
unknown
34
7
41
5
1
1
2
106
55
161
6
1
1
2
176
84
260
71
43
114
alive
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Material
119
120 Table 5: Complications Holter
Pudenz total
proximal obstruction
35
32
67
distal obstruction
59
30
89
combination
1
1
2
valve obstruction
5
5
10
disconnection
7
4
11
infection
5
12
17
112
84
196
system was seen in 17 patients (Holter 5, Pudenz 12).
Literature Forrest, D. M., D. G. W. Cooper: Complications of ventriculo-atrial shunts. A review of 455 cases. J. Neurosurg. 29 (19(58) 506-512 McLaurin, R. L.: Infected Cerebrospinal Fluid Shunts. Surg. Neurol. 1 (1973) 191-195 Noble, T. C, L. P. Lassman, W. Vrquhart, W. A. Aherne: Thrombotic and embolic complications of ventriculo-
atrial shunts. Devel. Med. Child. Neurol. 12 Suppl. 22 (1970) 114-122 Tischer,W.: Komplikationen der Ventrikulo-Kardialen Shuntoperationen bei Hydrozephalus. Kinderarzt. Prax. 57 (1969) 351-360 Tsingoglou, S., D. M. Forrest: Complications from Holter ventriculo-atrial shunts. Brit. J. Surg. 58 (1971) 372-377
/. W. F. Befes, Kliniek voor Neurochirurgie, Academisch Ziekenhuis, Groningen, Niederlande
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There were 110 revisions in 71 patients having a Holter-shunt and 80 revisions in 43 patients with a Pudenz - system. The mean of the total number of revisions was 1.66; for the Holtersystem 1.55 and for the Pudenzsystem 1.86. In 67 children with shunts the proximal catheter was bostructed: Holter-shunt 35; Pudenz-shunt 32 (table 5). 89 children suffered from a cardiac catheter - obstruction (Holter 59, Pudenz 30). Obstruction of both catheters was seen in 2 patients (Holter 1, Pudenz 1). Dysfunction of the valve was seen in 10 cases (Holter 5, Pudenz 5). Disconnection occurred in 11 patients (Holter 7, Pudenz 4). Infection of the shunt-
Results of the Treatment of Hydrocephalus with Ventriculo-Jugular Shunts J. W. F. Beks, M.D., C. A. ter Weeme, M.D.
Summary 260 children with hydrocephalus were treated with a ventriculo-jugular shunt. We compared the complication - rate between Holter-shunts and Pudenz-shunts. As far as we could verify 58 children died from several causes. 190 revisions were done in 114 patients, 110 revisions in 71 children with a Holter - valve and 80 revisions in 43 children with a Pudenz valve. The complication-rate was 112 in 176 Holter - valves and 84 in 84 Pudenz - systems. In our hands the use of the Holtersystem gives better results. As one can conclude from these figures and those from others (Tsingoglou and Forrest 1971), the treatment of children with hydrocephalus is still far from ideal.
avons comparé les taux de complications suivant l'utilisation des valves de Holter ou de Pudenz. Dans la mesure où nous avons pu le vérifier 58 enfants sont décédés pour plusieurs causes. 190 révisions ont été effectuées chez 114 sujets, 110 sur 71 enfants et 80 chez 43 enfants porteurs respectivement d'une valve de Holter ou de Pudenz. Les complications furent au nombre de 112 pour 176 Holter et de 84 pour 84 Pudenz. Entre nos mains le système Holter donne de meilleurs résultats. Ces chiffres, tout comme ceux d'autres auteurs (Tsingoglou et Forrest, 1971) amènent à conclure que le traitement des enfants hydrocéphales est loin d'être idéal.
Key words: hydrocephalus - shunt operation Holter valve - Pudenz valve
Although in the recent years much progress has been made in our knowledge of physiology of the cerebrospinal fluid and the diagnostic and therapeutic management of patients with disturbances of the circulation of this fluid, there are still many problems left. Widespread introduction of the ventriculojugular shunts has revolutionised the outlook for countless hydrocephalic infants and the success of this procedure is now well established. However with new methods of treatment come new diseases. There is a relative high frequency of complications and a high rate of revisions (Forrest c. s. 1968; Tischer 1969; Noble c. s. 1970; Tsingoglou 1971; Mc. Laurin 1973). The morbidity from ventriculo-jugular shunts is considered in order to form an impression of the morbidity of this kind of operation. We compared the complications of two kinds of ventriculo-jugular shunts, namely the Holter - valve and the Pudenz - system.
Zusammenfassung 260 Kinder mit Hydrocephalus wurden mit ventrikulo-jugularen Shunts behandelt. Wir verglichen die Komplikationsrate zwischen Holterund Pudenz-Systemen. So weit uns bekannt wurde, starben 58 Kinder aus verschiedenen Gründen. 190 Revisionen bei 114 Patienten wurden erforderlich, 110 Revisionen bei 71 Kindern mit Holter-Ventil und 84 bei 84 Pudenz-Systemen. In unserer Hand ergab die Verwendung von Holtersystemen bessere Ergebnisse. Wie man aus den Tabellen und den Ergebnissen anderer (Tsingoglou u. Forrest 1971) ersehen kann, ist die Behandlung von Kindern mit Hydrocephalus noch längst nicht ideal. Résumé Résultats du traitement de l'hydrocéphalie par les dérivations ventriculo-jugulaires. 260 enfants hydrocéphaliques ont été traités par une dérivation ventriculo-jugulaire. Nous
Introduction
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KNniek voor Neurochirurgie, Academisch Ziekenhuis, Groningen. The Netherlands.
Results of the Treatment of Hydrocephalus with Ventrico-Jugular Shunts
In a period from Jan. 1960 to Jan. 1973 260 hydrocephalic children were treated by ventriculo-jugular shunts in the University Clinic for Neurosurgery in Groningen. Of these patients 176 were treated, using the Holier - valve; 84 patients were treated using the Pudenz - system (table 1). These shunts were inserted in following the standard procedure. Table 1: Numbers of operated children with hydrocephalus Hoher
Pudenz total
with myelomeningocele
92
31
123
without myelomeningocele
84
53
137
176
84
260
Of these children 123 developed a hydrocephalus after closing a myelomeningocele, and in these cases primary operation was done during the first week of life.
In children in whom Holter - shunts have been inserted 11 died from meningitis, 4 by other infections, 10 from other causes and 11 unknown. In those children with a Pudenzshunt 9 died from meningitis, 8 from other causes and in 5 children the cause of death was unknown (table 3).
Table 3: Causes of death Holter meningitis
Pudenz total
11
9
20
4
0
4
other causes (tumours)
10
8
18
unknown
11
5
16
36
22
58
other infections
Revisions The of the shunt. in 114
most common indication for revision system was a dysfunctioning of the In total 190 revisions were performed children (table 4).
Mortality Of the total number of patients 58 died and of 41 we could not get further information; the remaining 161 are still alive. 36 of the patients who died, had a Holter - valve and 22 a Pudenz - Heyer apparatus (table 2).
Number of Revisions
Holter
Pudenz total
1
50
20
70
2
10
15
25
Pudenz total
3
7
5
12
Table 2: Follow-up Holter
Table 4: Frequency of operation for revision of shunts - of the 260 patients 114 required revision. Total revisions: 190
died
36
22
58
4
2
1
3
unknown
34
7
41
5
1
1
2
106
55
161
6
1
1
2
176
84
260
71
43
114
alive
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Material
119
120 Table 5: Complications Holter
Pudenz total
proximal obstruction
35
32
67
distal obstruction
59
30
89
combination
1
1
2
valve obstruction
5
5
10
disconnection
7
4
11
infection
5
12
17
112
84
196
system was seen in 17 patients (Holter 5, Pudenz 12).
Literature Forrest, D. M., D. G. W. Cooper: Complications of ventriculo-atrial shunts. A review of 455 cases. J. Neurosurg. 29 (19(58) 506-512 McLaurin, R. L.: Infected Cerebrospinal Fluid Shunts. Surg. Neurol. 1 (1973) 191-195 Noble, T. C, L. P. Lassman, W. Vrquhart, W. A. Aherne: Thrombotic and embolic complications of ventriculo-
atrial shunts. Devel. Med. Child. Neurol. 12 Suppl. 22 (1970) 114-122 Tischer,W.: Komplikationen der Ventrikulo-Kardialen Shuntoperationen bei Hydrozephalus. Kinderarzt. Prax. 57 (1969) 351-360 Tsingoglou, S., D. M. Forrest: Complications from Holter ventriculo-atrial shunts. Brit. J. Surg. 58 (1971) 372-377
/. W. F. Befes, Kliniek voor Neurochirurgie, Academisch Ziekenhuis, Groningen, Niederlande
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There were 110 revisions in 71 patients having a Holter-shunt and 80 revisions in 43 patients with a Pudenz - system. The mean of the total number of revisions was 1.66; for the Holtersystem 1.55 and for the Pudenzsystem 1.86. In 67 children with shunts the proximal catheter was bostructed: Holter-shunt 35; Pudenz-shunt 32 (table 5). 89 children suffered from a cardiac catheter - obstruction (Holter 59, Pudenz 30). Obstruction of both catheters was seen in 2 patients (Holter 1, Pudenz 1). Dysfunction of the valve was seen in 10 cases (Holter 5, Pudenz 5). Disconnection occurred in 11 patients (Holter 7, Pudenz 4). Infection of the shunt-
