Cumulative diagnostic radiation exposure in children with ventriculoperitoneal shunts: a review
ABSTRACT Children may be more vulnerable to diagnostic radiation exposure because of the increased dose-volume ratio and the increased lifetime risk per unit dose of radiation from early exposure. Moreover, recent radiological literature suggests that exposure to ionizing radiation from imaging studies may play a role in the later development of malignancies.
We review the literature and present two illustrative clinical examples of children (each child developed head and neck malignancies during their late teen years) with hydrocephalus requiring multiple cerebrospinal fluid (CSF) shunt revisions and diagnostic computerized tomography (CT) scans throughout their life.
The literature reviewed suggests that children are more prone to diagnostic radiation exposure. Although it is not possible to prove that the multiple diagnostic studies result in malignancies, our review of the literature and illustrative cases describing malignancy risk and radiation exposure should give clinicians pause when considering requesting multiple diagnostic CT studies in children during the evaluation of possible CSF shunt dysfunction. Alternative tests such as "shunt MRI" protocols should be considered for patients and used whenever possible to minimize exposure to ionizing radiation.
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ABSTRACT: The hydrocephalic patient is at risk throughout life of developing complications that may be severe or even fatal. The neurological, developmental, social and occupational outcome is affected by the sequelae of the initial disease and the consequences of intracranial hypertension, but also by imaginary obstacles. Unless proved otherwise, the patient with a shunt must be considered shunt-dependent; shunt independence is rare and must be proved following a rigorous protocol. The hydrocephalic patient should therefore be followed regularly and for life in neurosurgery to screen for and prevent complications as much as possible. Follow-up also allows patient education and coordination by the neurosurgeon and other specialists such as the neurologist and the physical therapist. Organizing the follow-up of the hydrocephalic patient into adulthood is the responsibility of the neurosurgeon in charge; the modalities of this follow-up will vary depending on local conditions. The patient should be educated on the need for this follow-up and prepared for this transition long before it occurs.Neurochirurgie 10/2008; 54(5):587-596. DOI:10.1016/j.neuchi.2008.07.002 · 0.47 Impact Factor
Article: Shunt failure.Journal of Neurosurgery Pediatrics 10/2010; 6(4):316-7; discussion 317. DOI:10.3171/2010.6.PEDS10229 · 1.37 Impact Factor
Article: The necessity of shunt series[Show abstract] [Hide abstract]
ABSTRACT: This work assessed the value of shunt series in the evaluation of children with CSF shunts, a test that is frequently ordered as part of the assessment of shunt integrity. The medical records of all children who underwent shunt series at Children's Hospital of Eastern Ontario between 1975 and 2007 were reviewed. Ancillary studies that were performed within 2 days of the shunt series (brain CT, MR imaging, ultrasonography, and radionuclide shuntography) were noted, as well as the subsequent requirement for a shunt revision. Shunt series and ancillary studies were categorized as either positive (revealing an observable sign that a shunt-related problem was present, such as shunt discontinuity on the shunt series or enlargement of the ventricles on the brain CT scan) or negative (no clear sign of a shunt-related problem). Shunt series were further grouped into shunt series performed for diagnostic reasons, shunt series performed on a routine basis during follow-up in clinic, and shunt series performed postoperatively. The length of time between shunt insertion and shunt fracture was noted. Statistical analyses were performed, including the derivation of sensitivities and specificities. There were 3416 shunt series in 394 patients, of which 3004 were performed with ancillary studies. On average, patients underwent 9 shunt series, with a minimum of 1 and a maximum of 43, during the follow-up period (range 3 weeks to 19 years). A total of 2493 shunt series and ancillary studies (83%) yielded negative results and no surgery was performed. One hundred thirty shunts series were negative with a positive ancillary study (4.3%) and no surgery was required. In 8.7% (261 shunt series negative, ancillary studies positive) shunt revision surgery was necessary. The opposite trend was far less prevalent (17 shunt series positive, ancillary test negative; 0.6%) in which surgery was required. There were 87 patients with 96 shunt fractures (2.8% of shunt series). The average time between shunt insertion and shunt fracture was 7.9 years (range 3 months to 18 years). Shunt series had a sensitivity of 18% and a specificity of 97%. The ancillary studies had a sensitivity of 84% and a specificity of 85%. The routine utilization of shunt series in the evaluation of a child with a CSF shunt is not necessary. This study showed that a very small number (0.6%) of shunt series helped in surgical decision making. Shunt series can be performed in selected cases, especially preoperatively in the absence of a baseline study to obtain information necessary for surgical planning.Journal of Neurosurgery Pediatrics 11/2010; 6(5):468-73. DOI:10.3171/2010.8.PEDS09557 · 1.37 Impact Factor