RESEARCH—HUMAN—CLINICAL STUDIES

TOPIC RESEARCH—HUMAN—CLINICAL STUDIES

Management of Adult Hydrocephalus With

Ventriculoperitoneal Shunts: Long-term Single-
Institution Experience
G. Kesava Reddy, PhD, MHA*
Papireddy Bollam, MD*
Runhua Shi, MD, PhD‡
Bharat Guthikonda, MD*
Anil Nanda, MD*
*Department of Neurosurgery and ‡Feist-
Weiller Cancer Center, Louisiana State
University Health Sciences Center,
Shreveport, Louisiana
Correspondence:
G. Kesava Reddy, PhD, MHA,
Assistant Professor of Research,
Department of Neurosurgery,
Louisiana State University Health
Sciences Center–Shreveport,
1501 Kings Hwy, PO Box 33932,
Shreveport, LA 71103-33932.
E-mail: kreddy_usa@yahoo.com
Received, January 20, 2010.
Accepted, March 10, 2011.
Published Online, June 16, 2011.
Copyright ª 2011 by the
Congress of Neurological Surgeons
BACKGROUND: Ventriculoperitoneal shunting is the most widely used neurosurgical
procedure for the management of hydrocephalus.
OBJECTIVE: To evaluate our long-term single-institution experience in the management
of adult hydrocephalus patients with ventriculoperitoneal shunts.
METHODS: Adult patients who underwent ventriculoperitoneal shunt placement for
hydrocephalus from October 1990 to October 2009 were included. Medical charts,
operative reports, imaging studies, and clinical follow-up evaluations were reviewed and
analyzed retrospectively for clinical outcome in adult hydrocephalus patients.
RESULTS: A total of 683 adult patients were included in the study. The most common
etiologies of hydrocephalus include idiopathic (29%), tumors and cysts (20%), post-
craniotomy (13%), and subarachnoid hemorrhage (13%). The overall shunt failure rate
was 32%, and the majority (74%) of shunt revisions occurred within the first 6 months.
The median time to first shunt revision was 9.31 months. Etiology of hydrocephalus
showed a significant impact on the incidence of shunt revision/failure and on the median
time to shunt revision. Similarly, the type of hydrocephalus had a significant effect on the
incidence of shunt failure and the median time to shunt revision.
CONCLUSION: A large proportion of patients (32%) experience shunt failure after shunt
placement for hydrocephalus. Although the overall incidence of shunt revision was
comparable to previously reported studies, the fact that a large proportion of adult
populations with shunt placement experience shunt failure is a concern.
KEY WORDS: Cerebrospinal fluid shunts, Hydrocephalus, Shunt complication, Shunt failure, Shunt revision,
Shunt surgery, Ventriculoperitoneal shunting

Neurosurgery 69:774–781, 2011 DOI: 10.1227/NEU.0b013e31821ffa9e www.neurosurgery-online.com

S
hunting of cerebrospinal fluid (CSF) re-
mains one of the most common neurosur-
gical procedures for the management of
patients with hydrocephalus. It is considered to be
a major province of neurosurgery, accounting for
70 000 annual hospital admissions in the United
States.1 Hydrocephalus represents a heterogeneous
group of disorders that span a wide range of
ages, from newborn to adult, with varying degrees
of severity, chronicity, and physiological states.
ABBREVIATIONS: CSF, cerebrospinal fluid; ICH,
intracranial hemorrhage; IVH, intraventricular
hemorrhage; NPH, normal-pressure hydroceph-
alus; SAH, subarachnoid hemorrhage; SDH,
subdural hemorrhage; VP, ventriculoperitoneal
Therefore, each patient requires a personalized
diagnostic and treatment approach.
Implantation of a ventriculoperitoneal (VP)
shunt is the most widely used treatment for
the management of hydrocephalus.2,3 Although
VP shunting of CSF reduces the morbidity
and mortality of hydrocephalus considerably, it is
associated with potential complications that may
require multiple surgical procedures, as well as
shunt revisions, during a patient’s lifespan.4 The
causes of shunt failure include infection, obstruc-
tion, overdrainage, and mechanical disconnection
or breakage.
Earlier studies evaluated shunt-associated
complications and shunt survival predominantly
in the pediatric hydrocephalus population; only
limited data are published in adult patients.4-7

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 MANAGEMENT OF ADULT PATIENTS WITH HYDROCEPHALUS

Similar to pediatric patients, adult patients with hydrocephalus

experience relatively high (29%) shunt failures requiring neu-
rosurgical interventions.6 The findings from long-term studies
show that 45% to 59% of all patients, regardless of age, expe-
rience shunt failures requiring a shunt revision with surgical
interventions.6,8 Thus, the treatment of hydrocephalus patients
with multiple VP shunt failures is a challenging problem in
neurosurgery. In the United States, revisions account for 48% of
all shunt-related procedures in hydrocephalus patients.1
Despite the significant advances in shunt technology and
treatment approaches in neurosurgery, the optimal management of
hydrocephalus in both pediatric and adult patients is yet to be
established. Specifically, the current shunting approaches seem to be
inadequate for alternative drainage of CSF in the management of
hydrocephalus. Except for normal-pressure hydrocephalus (NPH),
there is a paucity of literature and clinical studies pertaining spe-
cifically to the surgical management of adult hydrocephalus. Tra-
ditionally, the approaches offered for the management of adult
patients have been extrapolations of the experiences obtained from
treating pediatric patients.
Previous studies have shown that an increasing number of pre-
vious revisions and shorter time to first revision increase the risk of
shunt complications.4,9,10 The demographic factors that influence
shunt failures or the risk of shunt complications have yet to be fully
investigated. In this report, we retrospectively analyzed the patients
from the Louisiana State University Health Sciences Center–
Shreveport database over a 19-year period to examine the incidence
of VP shunt revision and its complication rates in adult patients. The
outcomes of this retrospective study may help to improve the sur-
gical management of hydrocephalus in adult patients.
FIGURE 1. Flowchart depicting the selection of patients for the study. ICH,
intracranial hemorrhage; IVH, intraventricular hemorrhage; SAH, sub-
MATERIALS AND METHODS arachnoid hemorrhage; SDH, subdural hemorrhage.

The Louisiana State University Health Sciences Center–Shreveport is

the primary neurosurgical referral center for the state of Louisiana. After
obtaining approval from the institutional review board, we compiled
a single institutional database (MD Analyze, Medtech Global Ltd.,
South Melbourne, Victoria, Australia) of patients treated at Louisiana
State University Health Sciences Center–Shreveport between October
1990 and October 2009 with International Classification of Diseases,
ninth revision, diagnostic codes for hydrocephalus. To comply with the
Health Insurance Portability and Accountability Act, confidentiality of
information was secured by the use of text encryption, password pro-
tection, and limited personnel involvement.
Patients $18 years of age who underwent primary shunt implantation
were included in the study. The details of the patients’ inclusion and
exclusion and their selection for the study are summarized in Figure 1. For
the 19-year period, medical charts, operative reports, imaging studies, and
clinical follow-up evaluations were reviewed retrospectively for all adult
hydrocephalus patients with surgical VP shunts. Information on each
patient, including age, sex, etiology of hydrocephalus, type of hydro-
cephalus, date of shunt placement, date of first and subsequent shunt
replacement or revisions, date of last follow-up, and cause of shunt
malfunction or failure, was collected from patient records.
The primary outcome of interest was the overall shunt revision rate and
the median time to shunt failure or revision in adult hydrocephalus patients.
Shunt failure was defined as the presence of clinical or radiological signs or
symptoms of shunt obstruction, breakage, malfunction, or infection leading
to shunt revision or replacement after the shunt insertion. Shunt mal-
function was further defined as the occurrence of symptoms in the presence
of elevated intracranial pressure, as detected with lumbar puncture, shunt
tap, or neuroimaging evidence of ventricular enlargement. Infection was
defined as the occurrence of symptoms in the presence of a positive CSF
culture obtained through lumbar puncture or shunt tap. The time to shunt
failure was defined as the time from the date of shunt placement to the date
of first shunt revision or failure. The patient diagnoses were grouped into
the following 7 different categories: idiopathic; tumors/cysts; subarachnoid
hemorrhage (SAH); postcraniotomy; posttraumatic; intracranial hemor-
rhage (ICH), subdural hemorrhage (SDH), or intraventricular hemorrhage
(IVH); and other. The ‘‘other’’ category included congenital, aqueduct
stenosis, meningitis, and spinal dysraphism.
Statistical Procedures
The x2 test was used to compare the proportion of the variable of
interest among the categorical variables. The Student t test or analysis of
variance was used to compare the continuous variables. The Kaplan-Meier
method was used to estimate the time to shunt failure, and the log-rank

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REDDY ET AL

test was used to compare the median time to shunt failure or revision in
adult patients with different etiologies and various hydrocephalus types. TABLE 2. Shunt Revisions by Etiology of Hydrocephalus in Adult
Patientsa
RESULTS Patients With Patients With
Patients Revision Revisions
In this retrospective study, a total of 1658 patients who un- (n = 683), (n = 221), in , 6 mo,
derwent shunting for hydrocephalus between October 1990 and Etiology n (%) n (%) n (%)
October 2009 were initially screened, and 683 adult patients with Idiopathic 201 (29) 36 (18) 18 (50)
VP shunt placement were included for the evaluation (Figure 1). Tumors/cyst 134 (20) 37 (28) 26 (70)
Of the 683 patients, 334 (49%) were male and 349 (51%) were Postcraniotomy 89 (13) 22 (25) 15 (68)
female. Approximately one-third of the patients were black, and SAH 83 (12) 39 (47) 35 (90)
two-thirds were white. Others represent ,1% of the total pa- Posttraumatic 62 (9) 29 (47) 24 (83)
tients included in the study. The median age of the patients was ICH/SDH/IVH 50 (7) 30 (60) 25 (83)
Other 64 (9) 28 (44) 20 (71)
55.6 years (range, 18.5-90.3 years; Table 1).
The most common etiologies of hydrocephalus in the patient a
ICH, intracranial hemorrhage; IVH, intraventricular hemorrhage; SAH, sub-
sample are presented in Table 2. These include idiopathic (29%), arachnoid hemorrhage; SDH, subdural hemorrhage.
tumors and cysts (20%), postcraniotomy (13%), SAH (12%),
posttraumatic (9%), ICH/SDH/IVH (7%), and other (9%). the 201 patients with idiopathic hydrocephalus, 36 (18%) had
The types of hydrocephalus in the patient sample are shown in shunt revision(s). Thirty-seven (28%) of the 134 patients with
Table 3. Of the 683 patients, 257 (38%) had communicating tumors/cysts, 22 (25%) of the 89 patients with postcraniotomy,
hydrocephalus, 125 (18%) had NPH, 289 (42%) had obstructive 39 (47%) of the 83 patients with SAH, 29 (47%) of the 62
hydrocephalus, and 12 (,2%) had other type of hydrocephalus. patients with posttraumatic, 30 (60%) of the 50 patients with
ICH/SDH/IVH, and 28 (44%) of the 64 patients with other
Shunt Revisions by Demographics etiology of hydrocephalus had shunt revision(s). Analysis with the
x2 test indicated that the incidence of shunt revision was sta-
Of the 683 patients with shunt placement, 221 (32%) expe- tistically significant among the 7 etiology groups (P , .001).
rienced $1 shunt failures requiring shunt revision(s). The in- Furthermore, most of the shunt revisions (50%-90%) occurred
cidence of shunt failure was similar between male and female (33% within the first 6 months of shunt placement, regardless of eti-
vs 32%) and between white and black (32% vs 33%) patients. Of ology. The incidence of shunt revisions within the first 6 months
the 221 patients with shunt failure, 163 (74%) had shunt of shunt placement was significantly lower in idiopathic hydro-
revision(s) within the first 6 months (Table 1). The incidence of cephalus compared with other etiology groups (P , .004).
shunt failure within the first 6 months of shunt placement was
similar in men and women (76% vs 72%; P . .05) and between Hydrocephalus Type and the Incidence of
whites and blacks (71% vs 81%; P . .05). Shunt Revisions
Etiology of Hydrocephalus and the Incidence of The incidence of shunt revision by hydrocephalus type is
Shunt Revisions presented in Table 3. Of the 257 patients with communicating
hydrocephalus, 94 (18%) experienced shunt revision requiring
The data in Table 2 show the incidence of shunt revision revision(s). In total, 107 (37%) of the 289 patients with
according to the etiology of hydrocephalus in adult patients. Of obstructive hydrocephalus, 15 (12%) of the 125 patients with
NPH, and 5 (42%) of the 12 patients with other hydrocephalus
experienced shunt revision. Analysis with the x2 test revealed that
TABLE 1. Demographics of Patients With Ventriculoperitoneal
Shunt Placement for the Management of Hydrocephalus
Patients With Patients With TABLE 3. Shunt Revisions by Hydrocephalus Type in Adult
Patients, Revision, Revisions in ,6 mo, Patients
Demographics n (%) n (%) n (%) P
Patients With Patients With
Total patients 683 (100) 221 (32) 163 (74)
Patients Revision Revisions in ,6 mo
Sex ..5
Hydrocephalus (n = 683), (n = 221), (n = 163),
Male 334 (49) 111 (33) 84 (76)
Type n (%) n (%) n (%)
Female 349 (51) 110 (32) 79 (72)
Ethnicity ..5 Communicative 257 (38) 94 (37) 72 (77)
White 478 (70) 153 (32) 108 (71) Normal pressure 125 (18) 15 (12) 6 (40)
Black 201 (29) 67 (33) 54 (81) Obstructive 289 (42) 107 (37) 81 (76)
Other 4 (1) 1 1 Other 12 (,2) 5 (42) 4 (80)

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 MANAGEMENT OF ADULT PATIENTS WITH HYDROCEPHALUS

the incidence of shunt revision was statistically significant among revisions owing to infection. Overdrainage of CSF accounted for
the patients with 4 hydrocephalus types (P , .001). About 76% the need for shunt revision(s) in 28 patients. Of the 28 patients,
to 80% of shunt revisions occurred within the first 6 months of 16 (57%) had a single shunt revision and 12 (43%) had multiple
shunt placement in patients with communicating, obstructive, revisions resulting from overdrainage. The findings on shunt
and other hydrocephalus types. In contrast, 60% of the shunt revisions within the first 6 months of shunt placement revealed
revisions occurred after 6 months of the shunt placement in that a higher proportion of cases (more than two-thirds of cases)
patients with NPH. Thus, the incidence of shunt revisions within with various causes of complications experienced shunt revisions
6 months of shunt placement differed statistically among the (Table 4).
patients with the 4 hydrocephalus types (P , .02).
Time to First Shunt Failure or Revision
Common Reasons for Shunt Revisions The results on the median time to first shunt failure or revision
Table 4 lists the most common reasons for shunt revisions in in adult hydrocephalus patients are summarized in Table 5 and in
adult patients with hydrocephalus. A total of 751 shunt revisions Figures 2 through 5. The overall median time to first shunt failure
occurred in 221 patients resulting from either complications such was 9.31 months (range, 6.2-14.1 months). No statistical dif-
as obstruction, infection, overdrainage, or other reasons for shunt ferences in median time to first shunt failure were noted between
complications. Shunt revision(s) resulting from obstruction the male and female patients or by ethnicity (P . .05, log-rank
occurred in 76 patients. Of these 76 patients, 28 (43%) had test). Kaplan-Meier analysis indicated that the median time to
a single shunt revision, and the remaining 53 (70%) had multiple shunt failure differed significantly between the patients in the
revisions owing to shunt obstruction. Infection accounted for 7 etiology groups (P , .001, log-rank test; Figure 4). Patients
a total of 41 shunt revision(s). Of the 41 patients, 32 (78%) with ICH/SDH/IVH had a shortest median time to first shunt
patients had a single shunt revision and 9 (22%) had multiple failure compared with other etiologies of hydrocephalus. Simi-
larly, the median time to shunt failure differed significantly
between the patients with the 4 hydrocephalus types (P , .001,
log-rank test; Figure 5). Patients with NPH had a longer median
TABLE 4. Revisions by Complication or Type of Revision Procedure time to first shunt failure compared with other hydrocephalus
in Adult Patients With Hydrocephalusa types.
Revision Revision Patients
Total With With With
Revisions Single Multiple Revisions
(n = 751), Occurrence, Occurrences, in ,6 mo,
Complication n (%)a n (%) n (%) n (%)
TABLE 5. Median Time to First Shunt Revision in Adult
Infection 41 (5.5) 32 (78) 9 (22) 29 (71) Hydrocephalus Patients (n = 683)a
Overdrainage 28 (3.7) 16 (57) 12 (43) 22 (79)
Median Time (Range) to First
Obstruction 76 (10.1) 48 (63) 28 (37) 53 (70)
Variable Shunt Revision, mo P
Proximal 86 (11.5) 65 (76) 21 (24) 62 (72)
shunt Sex ..05
complications Male 7.8 (5.4-16.0)
Distal 50 (6.7) 42 (84) 8 (16) 32 (64) Female 12.5 (5.5-NR)
shunt Race ..05
complications White 8.1 (5.4-20.1)
Externalization 39 (5.2) 34 (87) 5 (13) 28 (72) Black 10.0 (5.5-NR)
Shunt 134 (17.8) 109 (81) 25 (19) 97 (72) Etiology ,.001
complication Idiopathic .9.3 (8.1-NR)
Old shunt 131 (17.4) 114 (87) 17 (13) 99 (76) Tumors/cyst 6.2 (4.7-NR)
system Postcraniotomy 20.14 (3.0-20.1)
replacement SAH 0.53 (0.18 -12.0)
Adjustment 19 (2.5) 18 (95%) 1 (5) 13 (68) Posttraumatic 1.56 (0.20-16.0)
Valve 70 (9.3) 68 (97) 2 (3) 48 (66) ICH/SDH/IVH 0.35 (0.12-3.0)
replacement Other 4.6 (0.90-25.9)
Bactiseal 15 (2.0) 13 (87) 2 (13) 11 (73) Hydrocephalus type ,.001
catheter Communicating 7.8 (3.8-14.1)
Shunt 62 (8.3) 56 (90) 6 (10) 41 (66) Normal pressure .18.6 (8.1-NR)
system Obstructive 5.9 (3.1-16.0)
removal Other 3.1 (0.03-3.1)
a a
A total of 751 shunt revisions occurred owing to various causes/complications in ICH, intracranial hemorrhage; IVH, intraventricular hemorrhage; NR, not reached;
221 patients. SAH, subarachnoid hemorrhage; SDH, subdural hemorrhage.

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REDDY ET AL
FIGURE 2. Analysis of shunt survival in adult hydrocephalus patients ac-
cording to sex. Kaplan-Meier plot shows no statistical differences in the
median time to first shunt failure between male and female patients (log-rank
test, P . .05).
DISCUSSION
The management of hydrocephalus primarily involves the di-
version of CSF through shunts. Although CSF shunting provides
an improved neurological outcome, shunt devices have a high
propensity to malfunction, leading to shunt removal, replacement,
or revision.3,4 The causes for shunt malfunction include shunt
infection, overdrainage, obstruction, distal catheter migration,
shunt disconnection, and wound breakdown involving shunt,
which can occur either alone or in any combination.
In this study, we retrospectively evaluated the 683 adult pa-
tients who underwent VP shunt placement for hydrocephalus at
FIGURE 3. Analysis of shunt survival in adult hydrocephalus patients ac-
cording to ethnicity. Kaplan-Meier plot shows no statistical differences in the
median time to first shunt failure between black and white patients (log-rank
test, P . .05).
778 | VOLUME 69 | NUMBER 4 | OCTOBER 2011
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FIGURE 4. Analysis of shunt survival in adult hydrocephalus patients ac-
cording to etiology. Kaplan-Meier plot demonstrates significant differences in
the median time to shunt failure between the different etiologies in adult
hydrocephalus patients (log-rank test, P , .001). ICH, intracranial hemor-
rhage; IVH, intraventricular hemorrhage; SAH, subarachnoid hemorrhage;
SDH, subdural hemorrhage.
our institution from October 1990 to October 2009. Specifically,
the study examined the incidence of shunt revision by sex, race,
etiology of hydrocephalus, type of hydrocephalus, and various
causes of shunt revisions in adult patients. To the best of our
knowledge, this is the largest study evaluating the management of
hydrocephalus involving a cohort of 683 adult patients from
a single institution.
This study is subject to a number of important limitations. It is
a retrospective study that explores the clinical outcome in adult
hydrocephalus patients after shunt placement. Thus, this study has
limitations inherent to its retrospective design. First, diagnostic and
FIGURE 5. Analysis of shunt survival according to hydrocephalus type in adult
patients. Kaplan-Meier analysis indicates significant differences in the median
time to shunt failure between the 4 hydrocephalus types (log rank test,
P , .001). NPH, normal-pressure hydrocephalus.
www.neurosurgery-online.com

therapeutic procedures did not follow a predefined scheme, which
may have biased the interpretation of the results; in particular, the
variables included in this study could not be analyzed in a con-
trolled way. Although a uniform technique for VP shunt placement
was used, the overall treatment was chosen by a number of neu-
rosurgeons and residents under training. Therefore, many of these
variables included in this retrospective study are dependent on the
decisions of individual neurosurgeons and surgical procedures
involved for the shunt placement. It is theoretically possible that
the study results could be affected by the different criteria of
different surgeons for performing shunt placement or shunt re-
operation. Nevertheless, we believe that our retrospective analysis is
valuable and has several strengths. Importantly, this analysis in-
cludes a large population of adult patients over a 19-year period.
We were able to evaluate long-term shunt survival and the impact
of the etiology and type of hydrocephalus on shunt failure in adult
hydrocephalus patients. The other strength of the study is the in-
depth standardized approach that we undertook to investigate
shunt complications such as infection, obstruction, overdrainage,
and other mechanical complications, which demonstrated a de-
tailed picture of causes for shunt failure in adult neurosurgical
patients. However, randomized prospective studies are needed to
better evaluate risk factors that contribute to shunt failure in adult
hydrocephalus patients.
It is well established that adult patients with hydrocephalus
have far fewer shunt failures than pediatric patients, with reported
shunt failure rates of 18% to 29% for adult hydrocephalus
patients4,5,7,11 compared with 44.3% to 81% for pediatric hy-
drocephalus patients.12-14 In addition, earlier studies have shown
an overall 10-year shunt failure rate of 30% to 40% and that
shunt failures most commonly occur within 6 months post-
operatively in pediatric patients. The results from this study show
that the overall incidence of shunt revision was 32% in adult
hydrocephalus patients. Although the observed incidence of
shunt revision in adult hydrocephalus patients is marginally
higher in the present study, our results are closely comparable to
those reported previously.4,15 Recently, Wu et al4 reported that
adult hydrocephalus patients experienced a 27% shunt compli-
cation rate requiring revision after shunt surgery. More recently,
we reported that 52 (28%) of 187 patients with intracranial
tumors experienced $1 shunt revisions after shunt placement for
hydrocephalus.16 Similarly, it has previously been shown that 102
(29%) of 356 adult patients experienced $1 shunt revisions after
shunt placement for hydrocephalus.15 However, Lund-Johansen
et al7 have shown that 17 (18%) of 95 adult patients required
shunt revisions for hydrocephalus.
The higher incidence of shunt revision observed in the present
study could be explained in different ways. Shunt infection, ob-
struction, overdrainage, and mechanical shunt complications are
the major contributors to shunt revision in hydrocephalus patients.
Moreover, shunt design, valve type, and shunt material may play
a role in shunt survival in these patients. To optimize shunt sur-
vival, studies evaluated the surgical procedures and shunt valve
types in prospective randomized trials in hydrocephalus patients. In
NEUROSURGERY
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MANAGEMENT OF ADULT PATIENTS WITH HYDROCEPHALUS
a multicenter randomized endoscopic shunt insertion trial, Kestle
et al17 observed that endoscopic insertion of the initial shunt did
not reduce the incidence of shunt failure compared with non-
endoscopic insertion of the initial shunt in pediatric hydrocephalus
patients. A multicenter randomized shunt design trial conducted in
12 North American and European centers demonstrated that
shunt design had no significant impact on the time to first shunt
failure in hydrocephalus patients.18
An analysis of our findings does not show significant differ-
ences in shunt placement or shunt revision rates between men
and women and between whites and blacks (Table 1). In addi-
tion, our results show that neither sex nor ethnicity had an impact
on shunt revision rate within the first 6 months of shunt
placement. A recent report by Farahmand et al9 indicates that sex
has no significant impact on the incidence of shunt revision rate
within the first 6 months of shunt placement. Similarly, others
have shown that ethnicity was not associated with shunt revision
in patients with hydrocephalus.4
The results of the study reveal that the etiology of the hydro-
cephalus seems to have some relation to shunt revision rate in adult
patients. Although the study is not focused primarily on examining
the effect of the specific etiology, x2 analysis indicated that the
patients with ICH/SDH/IVH had a higher incidence of shunt
revision and a shorter median time to shunt failure. In contrast,
patients who underwent shunt insertion for other etiologies, in-
cluding SAH, posttraumatic, tumors/cysts, and postcraniotomy,
had a lower incidence of shunt revision and a relatively longer
median time to shunt failure. Similar findings have been reported
recently by our group in pediatric hydrocephalus patients.19,20
However, further studies are required to evaluate the precise re-
lationship between the incidence of shunt revision and specific
etiology of hydrocephalus in adult patients.
An analysis of shunt revisions in relation to hydrocephalous
type indicated that obstructive hydrocephalus was the most
common accompanying diagnosis, followed by communicating
hydrocephalus and NPH, in adult patients. Among adult
patients, both communicating and obstructive hydrocephalus
patients showed similar incidence of shunt revisions and shorter
median time to shunt revision, whereas NPH patients had much
lower shunt revision incidence and longer median time to shunt
revision. Conversely, the shunt revision rate within the first
6 months after shunt insertion was significantly higher in com-
municating and obstructive hydrocephalus patients than in NPH
patients. Further studies are needed to explain these discrepancies
in the revision rates and median time to first shunt revision
among various types of hydrocephalus in adult patients.
Infection, obstruction, and overdrainage are major causes of
shunt malfunction resulting in shunt revision in hydrocephalus
patients. Many of these complications are believed to be directly
related to surgical procedure and patient management. Therefore,
in this study, we evaluated these major causes and other compli-
cations in relation to shunt revision in adult hydrocephalus
patients. Our results show that shunt infection accounted for 5.5%
of total revisions, whereas shunt obstruction and overdrainage
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REDDY ET AL
accounted for 10% and 3.7% of the total revisions, respectively.
Furthermore, the majority of shunt revisions occurred within the
first 6 months of shunt placement, regardless of the complication,
in adult hydrocephalus patients.
Overall, the results of this study and previous studies show
a relatively high shunt revision rate and shorter time to first shunt
revision in adult hydrocephalus patients. On the basis of these
unfavorable results, several studies have focused on improving
shunts by developing material and valve mechanisms.21-23 Fur-
thermore, endoscopic neurosurgery has been developed as an
alternative to avoid open surgery or shunt insertion–related ad-
verse events. Currently, we are exploring the clinical benefits of
endoscopic third ventriculostomy as a plausible treatment option
for certain patients with hydrocephalus. Although the sample size
was very small, the initial outcome of endoscopic third ven-
triculostomy seems to be interesting and encouraging. Our future
studies will assess the clinical outcomes of endoscopic third
ventriculostomy in the management of adult hydrocephalus.
CONCLUSION
In this retrospective study, we evaluated the management of
hydrocephalus in 683 adult patients. Specifically, the study
examined various factors, including the etiology of hydroceph-
alus, type of hydrocephalus, and indications affecting the overall
incidence of shunt revisions and time to shunt failure in adult
patients. Although the overall incidence of shunt revision was
comparable to that in previously reported studies, a large pro-
portion of patients experience shunt failure after shunt placement
for hydrocephalus. The fact that 32% of adult patients with shunt
placement experience shunt failure reminds us that the current
treatment for hydrocephalus is not optimal for a large proportion
of patients. Prospective randomized studies are required to elu-
cidate the risk factors that contribute to shunt failure in adult
hydrocephalus patients. Currently, we are exploring the clinical
utility of minimally invasive microneurosurgical techniques,
including endoscopic third ventriculostomy, for the management
of obstructive hydrocephalus in both pediatric and adult patients.
Disclosure
The authors have no personal financial or institutional interest in any of the
drugs, materials, or devices described in this article.
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Acknowledgment
We acknowledge that Dr Anil Nanda received authorship as a contributing
author for the article for his generosity in providing resources such as database to
conduct this research.
COMMENTS
T he authors provide a detailed retrospective view of their practice at
a single institution over 20 years with the management of adult
hydrocephalus. The most important point to be taken from this article is
that shunt failure rates for adults are high and are similar in degree to
those reported in the pediatric population. Other publications with
www.neurosurgery-online.com

smaller numbers confirm this observation. The reasons for these failure
rates are not clear from such a study. The authors note that etiology may
play a role in shunt revisions, but these conclusions are difficult to
validate because of limitations in study design. It seems that patients with
intracranial hemorrhage, intraventricular hemorrhage, or subdural
hemorrhage have higher shunt failure rates, but the reason for this
finding is unclear. Overall, this study should stimulate a greater effort to
study shunt failure in adults in a prospective manner. Although ran-
domized studies in children have not generally shown benefit from newer
tools such as endoscopic placement or programmable shunts, there is
a great deal to be gained by studying ways to reduce shunt failure rates.
Nalin Gupta
San Francisco, California
NEUROSURGERY
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
MANAGEMENT OF ADULT PATIENTS WITH HYDROCEPHALUS
T his is a retrospective chart review of adult patients who had ven-
triculoperitoneal shunts. The purpose was to determine risk factors
for shunt failure and to obtain natural history data. The findings were
that adult shunts fail with a pattern similar to that of pediatric patients.
The use of navigation and programmable shunts had no effect, as has
been reported with children. The only factor that predicted outcome was
etiology of the hydrocephalus: as one would expect, patients with in-
traventricular hemorrhage failed with increased frequency, presumably
because the cerebrospinal fluid was filled with debris. Normal-pressure
hydrocephalus patients failed with less frequency, presumably because
many of them were probably not shunt dependent.
Leslie N. Sutton
Philadelphia, Pennsylvania
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