Perspectives
Commentary on:
Failed Ventriculoperitoneal Shunt: Is
Retrograde Ventriculosinus Shunt
a Reliable Option?
by Oliveira et al. World Neurosurg 92:445-453, 2016
Management of Challenging Hydrocephalus Scenarios: Clinical Perspective
Samer K. Elbabaa1 and Pablo Gonzalez-Lopez2
T he cerebrospinal fluid (CSF) shunt remains as the most
common treatment choice for nonobstructive hydro-
cephalus worldwide. The morbidity and mortality related
to shunt malfunctions and infections continue to carry heavy
clinical and economical tolls on patients, families, and health care
systems. Shunts are considered as life-saving devices but are
notorious for high failure rates. The neurosurgical literature is rich
with many retrospective and prospective studies looking at risk
factors for shunt malfunction, as well as new and improved ways
to reduce shunt-related morbidity and mortality.1 Over the past
2 decades, many developments of new adjuncts, such as the
use of frameless stereotaxy, ultrasound, and antibiotic-
impregnated catheters, may explain the improvement in CSF
shunt survivals from a multicenter composite cohort (1990s) to a
modern 2007e2012 cohort as reported by Kulkrani et al2 in 2013.
The pediatric hydrocephalus systematic literature review and
evidence-based guidelines found insufficient evidence to
demonstrate an advantage for 1 shunt hardware design over
another in the treatment of pediatric hydrocephalus.3
In a paper recently published in WORLD NEUROSURGERY, Oliveira
and colleagues share their experience with using the retrograde
ventriculosinus shunt (VSS) in adult patients with failed ven-
triculoperitoneal shunts (VPS). They concluded that when VPS is
not feasible, VSS is a safe second option with potential advan-
tages such as lower risk of overdrainage and good functional
results. Their series excluded pediatric and normal pressure hy-
drocephalus (NPH) patients. The VSS was implanted via the El-
Shafei technique using a valveless shunt catheter from the
Key words Abbreviations and Acronyms
- Failed ventriculoperitoneal shunt CSF: Cerebrospinal fluid
- Hydrocephalus ETV: Endoscopic third
- Neurosurgery ventriculostomy
- Retrograde ventriculosinus shunt ICP: Intracranial pressure
IJV: Internal jugular vein
VAS: Ventriculoatrial shunt
VPS: Ventriculoperitoneal shunt
VSS: Ventriculosinus shunt
WORLD NEUROSURGERY 96: 599-601, DECEMBER 2016
lateral ventricle into the superior sagittal sinus. The intravenous
portion of the catheter was inserted against the direction of blood
flow within the superior sagittal sinus, using the impact pressure
at the tip of the catheter to make the stabilized intracranial
pressure (ICP) higher than the venous pressure. Theoretically,
this will avoid overdrainage secondary to posture or changes in
the intrathoracic pressure.4-6
For more than 50 years, neurosurgeons and biomedical engi-
neers invested many efforts to improve the designing of shunt
hardware, although the overall concept remains unchanged
except for a few advances. The advances are focused on con-
trolling the CSF flow, as well as lowering the shunt malfunction
and infection rates. Approximately 40% of shunts fail within 2
years after first implant, and more than 95% fail within 10 years.
Classically, shunt obstruction is the cause of shunt malfunction.
The proximal ventricular catheter is obstructed in 60%, the valve
in 30%, and the distal catheter in 10% of patients with shunt
malfunction. There are continued efforts to reach the smart
shunt, a concept defined as an implantable system (hardware
and algorithms) designed to control CSF drainage on the basis of
the feedback from sensors within the system (ICP, posture po-
sition, and CSF flow). The concept of a smart shunt can allow the
surgeon to access historical data such as ICP and CSF flow
patterns.1
In a recent comprehensive prospective observational study
conducted by the Hydrocephalus Clinical Research Network
aiming to isolate specific risk factors for shunt failure in pediatric
From the 1Division of Pediatric Neurosurgery, Department of Neurological Surgery, St. Louis
University School of Medicine, St. Louis, Missouri, USA; and 2Department of Neurosurgery,
Neurooncology and Skull Base Unit, Miguel Hernandez University Hospital General
Universitario de Alicante, Alicante, Spain
To whom correspondence should be addressed: Samer K. Elbabaa, M.D.
[E-mail: selbabaa@slu.edu]
Citation: World Neurosurg. (2016) 96:599-601.
http://dx.doi.org/10.1016/j.wneu.2016.08.119
www.WORLDNEUROSURGERY.org 599
PERSPECTIVES

patients (mostly VPSs), hardware variables such as valve design,
valve programmability, and peritoneal entry method were not
associated with increased rates of CSF shunt failure.7
VPSs are the most commonly used CSF shunts draining into the
peritoneal cavity because of their simplicity and low rate of
complications. The peritoneum has a large absorptive surface
and accommodates large volumes of CSF per day. In some
patients, many abdominal conditions such as peritoneal adhe-
sions, history of peritonitis or shunt infections, history of mul-
tiple laparotomies, or suboptimal peritoneal catheter position
can lead to frequent distal VPS malfunctions, usually in the form
of infected or sterile abdominal pseudocysts requiring shunt
externalization. After multiple failed VPS attempts, surgeons
classically try converting VPSs into either ventriculoatrial shunts
(VASs) or ventriculopleural shunts.8 Both atrial and pleural
shunts have their own limitations and risks, especially in the
very young pediatric population. Risks of VASs include
thromboembolic complications and high revision rates. The
most common risks of pleural shunts include CSF
underabsorption leading to progressive pleural effusion and
respiratory distress.
It was suggested by El-Shafei that the most physiologic way of
treating hydrocephalus is by establishing a watertight connection
that will drain CSF into the upper end of the internal jugular vein
(IJV) or a dural sinus against the direction of blood flow. On the
basis of early results, there were no common complications
related to incorrect or suboptimal CSF drainage or thromboem-
bolic complications in patients undergoing VSS, although there
were considerable difficulties placing the shunts into IJVs in
infants and young children because of the small caliber of neck
veins. The IJV is a collapsible tube with contour change capa-
bilities according to changes in its transmural pressure, acting as
a self-regulating siphon control mechanism, which protects the
ICPs against the effect of gravity and posture.5 The technique of
placing the distal end of the catheter into the sagittal sinus carries
the risk of excessive bleeding or air embolism, although a
modification of the technique using a Seldinger guidewire
technique was described by Samadandi et al.9
An experimental study by Van Canneyt et al10 using a built model
of the cerebral ventricles, the arachnoid villi, and the superior
sagittal sinus to assess the VSS concluded that no
overdrainage was found in either the antegrade or retrograde
position of the sinus shunt. Their optimal results were obtained
with the shunt positioned in the most downstream half of the
superior sagittal sinus.10 Toma et al11 carried a literature search
reviewing 7 VSS clinical series with a total of 265 patients.
None of the patients developed venous sinus thrombosis, air
embolism, or excessive intraoperative sinus bleeding.11
Patients with frequent failures of CSF shunts are best managed
by neurosurgeons who are experienced in converting VPSs into
other less commonly used shunts such as VASs, ven-
triculopleural shunts, or VSSs. The option of complete removal of
a problematic shunt followed by performing an endoscopic third
ventriculostomy (ETV) in patients with a history of obstructive
hydrocephalus (preferably due to idiopathic aqueductal stenosis)
can be the treatment of choice in such scenarios. ETV, after
shunt removal, can have a success rate ranging from 40%!
100% when other ETV risk factors for failure such as shunt
infection and age <6 months are being considered.12 The
success rate of secondary ETV in well-selected cases is not
different from that of primary ETV. Many experts consider it
reasonable to offer all patients with frequently failed shunts and
suitable anatomy indicating an obstructive cause the opportunity
for shunt independence regardless of the original cause of the
hydrocephalus.13
Surgeons who are inherently opposed to the concept of
attempting conversion of problematic and frequently failed VPSs
into other types of less commonly used shunts such as VAS or
VSS, or even achieving shunt independence via ETV in appro-
priate patients, argue that such surgical treatments achieve low
success rates at the expense of higher morbidity rates. The
experience of Oliveira and colleagues treating failed VPS patients
with retrograde VSS leading to acceptable success rates with
low morbidities in their adult patients is another unconventional
example of thinking outside the box while treating challenging
patients with shunted hydrocephalus.

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PERSPECTIVES
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1878-8750/$ - see front matter 2016 Elsevier Inc. All
rights reserved.
Citation: World Neurosurg. (2016) 96:599-601.
http://dx.doi.org/10.1016/j.wneu.2016.08.119
www.WORLDNEUROSURGERY.org 601