Our initial Hydrocephalus Research Agenda.

Reducing infections associated with shunt surgery.

Approximately 8-10% of shunt operations result in infections. Shunt infection requires treatment in hospital for an average of 10-14 days and correlates with a worsened long term prognosis for patients with hydrocephalus. Our investigators will study a quality improvement technique for reducing surgery-related shunt infection. Such a study has the potential to reduce the incidence of infection thereby reducing hospital stay and patient morbidity.

Understanding the epidemiology and outcomes of Endoscopic Third Ventriculostomy, or ETV.

ETV is widely used in Europe to treat hydrocephalus and is used in North America to a much lesser extent. Our investigators would like to understand when the procedure is indicated and what its associated outcomes and complications are. The use of ETV is attractive since infection should be very rare and some of the other complications associated with shunts (slit ventricles) should also be very rare. It is therefore important for us to understand the patients in whom ETV is appropriate.

Creating a detailed registry of all hydrocephalus patients at participating institutions.

A large scale registry will allow us to track trends over time and to identify inter-institutional variation. A registry will allow researchers to quickly test hypotheses to help generate future studies for improving the care for hydrocephalus patients.

Improving shunt placement using ultra-sound guidance.

Based on the Endoscopic Shunt Insertion Trial (Kestle J, Drake J, et al. Lack of benefit of endoscopic ventriculoperitoneal shunt insertion: A multicenter randomized trial. J Neurosurg 98: 284-290, 2003), the position of the ventricular catheter after surgery is an important factor in how long the shunt lasts. Using ultrasound, the trajectory for placement of the shunt can be planned, so that it ends up in a good position. This technique will be investigated and, if it appears to be promising, we will publish guidelines widely to help increase shunt survival and decrease shunt re-operations for blockage.

Management of hydrocephalus in premature children.

Two different surgical procedures that are commonly used to manage IVH-induced hydrocephalus in premature children will be evaluated. A subgaleal reservoir is an implant that consists of a tube which goes into the ventricle attached to a silicone bubble that sits under the skin. As fluid accumulates in the ventricle it can be removed by a needle puncture through the skin into the silicone bubble. The other option is a subgaleal shunt which is similar to a reservoir except that the silicone bubble under the skin has an opening in the side so that fluid from the ventricle flows through the bubble and out under the skin. The child usually develops a very large pocket of fluid on their head, but tapping with a needle is not required – the fluid under the skin gets absorbed into the tissues. These two techniques will be compared with respect to the need for permanent shunting afterward and related complications.

Treatment of CSF shunt infection.

CSF shunts often require surgical revision, and each surgery increases the risk of infection. CSF shunt infections lead to prolonged hospitalizations, high expenditures, repeated shunt revision surgeries, and re-infection at rates as high as 25 percent. A recent NIH workshop highlighted a need to optimize treatment of CSF shunt infection and prevent CSF shunt re-infection. Using the HCRN longitudinal cohort in the registry, we will determine if different durations of antibiotic therapy and/or surgical approaches to infection therapy, are associated with re-infection.