Parent/guardian knowledge regarding implanted shunt type, setting, and symptoms of malfunction/infection.

OBJECTIVE Patients with shunts often interact with providers distant from their primary hospital, making it important that the parent(s)/guardian(s) is well versed in the type of shunt implanted and symptoms of malfunction/infection. This is particularly important with magnetic-sensitive programmable valves, as the use of MRI becomes more prevalent. METHODS Over a 6-month period, primary caregivers of 148 consecutive patients who received shunts were prospectively administered questionnaires at clinic visits. Caregivers were asked to do the following: 1) identify shunt valve name, type, and setting if applicable; 2) list symptoms of shunt malfunction/infection; and 3) indicate whether they had access to references regarding shunt type/setting, booklets from the Hydrocephalus Association, and quick reference cards with symptoms of shunt malfunction/infection. One cohort of caregivers (n = 75) was asked to carry informational cards with shunt valve/setting information (group I); this cohort was compared with another subgroup of caregivers (n = 73) not carrying cards (group II). RESULTS The mean (± SD) age of patients at implantation/revision was 3.71 ± 4.91 years, and the age at follow-up was 6.12 ± 5.4 years. The average time from surgery to administration of the questionnaire was 2.38 ± 3.22 years. There were 86 new shunt insertions and 62 revisions. One hundred twenty-eight caregivers (87%) could identify the type of valve (programmable vs nonprogrammable). On the other hand, only 72 caregivers (49%) could identify the valve name. Fifty-four of 73 (74%) caregivers of patients who had shunts with programmable valves could correctly identify the valve setting. One hundred caregivers (68%) had a copy of the Hydrocephalus Association booklet, and 103 (70%) had quick reference cards. Eighty caregivers (54%) had references on shunt type/setting. Most caregivers (127 [86%]) could name ≥ 3 signs/symptoms of shunt malfunction, with vomiting (61%), headache (49%), and sleeps more/lethargic (35%) most frequently reported. Caregivers of patients in group I were more likely to have cards with symptoms of shunt infection or malfunction (p = 0.015); have information cards regarding shunt type/setting (p < 0.001); and correctly identify valve type (p = 0.001), name (p < 0.001), and setting if programmable (p = 0.0016). There were no differences in ability to list symptoms of shunt malfunction or infection (p = 0.8812) or in access to Hydrocephalus Association booklets (p = 0.1288). There were no significant demographic differences between the groups, except that group I patients had a shorter time from surgery to last follow-up (1.66 vs 3.17 years; p = 0.0001). CONCLUSIONS Education regarding the care of patients with shunts by providing written cards with shunt type/setting and access to reference materials seems to be effective. Developing plans for guided instruction with assessment in the clinic setting of a caregiver's knowledge is important for patient safety.

Quality of life after endoscopic third ventriculostomy and cerebrospinal fluid shunting: an adjusted multivariable analysis in a large cohort.

OBJECT: Quality of life (QOL) studies comparing treatment with endoscopic third ventriculostomy (ETV) and CSF shunting are very limited. The authors compared QOL outcomes following these 2 treatments in a large cohort of children with hydrocephalus by using multivariable statistical techniques to adjust for possible confounder variables. METHODS: The families of children between 5 and 18 years of age with previously treated hydrocephalus at 3 Canadian pediatric neurosurgery centers completed measures of QOL: the Hydrocephalus Outcome Questionnaire (HOQ) and the Health Utilities Index Mark 3 (HUI3). Medical records and recent brain imaging studies were reviewed. A linear regression analysis was performed with the QOL measures as the dependent variable. In multivariable analyses, the authors assessed the independent effect of initial hydrocephalus treatment (ETV vs shunting) while adjusting for the treatment center, current patient age, age at initial treatment, etiology of hydrocephalus, total number of days spent in the hospital for initial treatment, total number of days spent in the hospital for subsequent hydrocephalus complications, functioning ETV at follow-up assessment, frequency of seizures, and current ventricle size. RESULTS: Data from 603 patients were available for analysis. Fifty-eight patients had undergone ETV as their primary treatment and 545 had undergone CSF shunting. Endoscopic third ventriculostomy patients were slightly younger at the follow-up assessment, were older at the first surgery, and spent fewer days in the hospital for hydrocephalus complications. Without adjustment for any confounders, treatment with ETV was associated with significantly higher HOQ physical scores and HUI3 scores. After multivariable adjustment, however, there was no significant difference in any outcome measure. A functioning ETV at the time of the follow-up assessment was not significant in any model. CONCLUSIONS: Treatment with either ETV or CSF shunting does not appear to be associated with any substantial difference in QOL outcome after adjusting for prognostic factors. Further study is needed to definitively determine the relative QOL benefit of either procedure, if any.

Math and numeracy in young adults with spina bifida and hydrocephalus.

The developmental stability of poor math skill was studied in 31 young adults with spina bifida and hydrocephalus (SBH), a neurodevelopmental disorder involving malformations of the brain and spinal cord. Longitudinally, individuals with poor math problem solving as children grew into adults with poor problem solving and limited functional numeracy. As a group, young adults with SBH had poor computation accuracy, computation speed, problem solving, a ndfunctional numeracy. Computation accuracy was related to a supporting cognitive system (working memory for numbers), and functional numeracy was related to one medical history variable (number of lifetime shunt revisions). Adult functional numeracy, but not functional literacy, was predictive of higher levels of social, personal, and community independence.

The effects of multiple shunt revisions on neuropsychological functioning and memory.

The focus of this study was to determine the effect of multiple shunt revisions on cognition and memory. The present study attempted to document a discrepancy in the functioning of children with hydrocephalus having numerous shunt revisions compared to those with only an initial shunt surgery. Researchers have found an increasing number of children with hydrocephalus requiring shunt revisions. In the current literature there are many conflicting views regarding the effects of hydrocephalus on cognition and memory. Many researchers report that properly treated hydrocephalus will not have a negative impact on cognitive functioning. Furthermore, researchers found that factors such as the total number of shunt revisions do not negatively impact global intellectual ability. Forty-six subjects between the ages of six and 16 years participated in the study. The subjects were recruited from the Department of Neurosurgery at an urban pediatric hospital. Specific inclusion and exclusion criteria were met. Independent variables for the study included shunt revisions, seizures, and Attention Deficit Hyperactivity Disorder (ADHD). Subject groupings were based on whether the subjects required multiple shunt revisions or single shunt placement and the presence or absence of seizures and ADHD. Dependent variables included the subject's performance on measures of cognition and memory. Measures of functioning included the Wechsler Intelligence Scale for Children--Third Edition and the Wide Range Assessment of Learning and Memory-Screener. The results of this study did not support the presence of cognitive or memory impairments as a result of multiple shunt revisions. Anecdotal findings noted that seizures were the only independent variable to significantly account for the observed variance in scores of cognition, specifically Full Scale IQ, Verbal Comprehension, and Perceptual Organization.

Intelligence outcome in children with shunted hydrocephalus of different etiology.

Children with shunted hydrocephalus of differing etiologies were assessed. There was a more selective loss of non-verbal than of verbal intelligence. The verbal and visuo-perceptual abilities were affected by different sets of variables. Variables related to the hydrocephalus had no effects, while associated supratentorial malformations significantly affected non-verbal functions.

Behavioural problems in children with infantile hydrocephalus.

The occurrence of behavioural problems in a population-based series of children with infantile hydrocephalus (non-spina bifida) was analysed, using parent questionnaires. Children with both infantile hydrocephalus and mental retardation had significantly more behavioural problems compared with those with no mental retardation and controls. Inattentiveness and hyperactivity were particularly typical. No differences were found between children with infantile hydrocephalus and no mental retardation and the control group.

Life conditions of adolescents with myelomeningocele.

Twenty six adolescents with myelomeningocele have been followed from birth: they comprise the whole population born with myelomeningocele between 1964 and 1967 in one Swedish medical district. 18 have severe physical handicaps, and although there are equal numbers of males and females, more females have severe handicaps, 22 of the 26 have been educated in normal schools (19 in normal classes), but learning difficulties are common. Three other adolescent are mildly mentally retarded and one is severely so. Only seven have complete urinary continence. 19 take part in leisure-time activities, but many felt they had poor social contact with their schoolmates and one in three were competent in activities of daily living. In general, self-concept was poor and many had inadequate knowledge about sexuality and the cause of their handicap. Recently established Handicapped Adult Teams have proved important in providing a link between the adolescent and public services dealing with health, education, employment and social services.

Intelligence and achievement in children with myelomeningocele.

Intelligence and achievement test scores for 89 children with myelomeningocele (MM), ages 4 to 14 years, were obtained from medical records. These children scored below the population average but within the normal range on most tests. The greatest deficits occurred on Performance IQ, arithmetic achievement, and visual-motor integration (copying geometric designs). With increasing age, these children fell further behind age-peers on tests of arithmetic and visual-motor performance while keeping pace on reading and spelling tests. We speculate that these findings may reflect a developmental difference between MM children and nonhandicapped children in a visual-perceptual-organizational cognitive function such as Rourke (1987) has proposed.

Psychosocial adaptations of shunted hydrocephalic children.

The personality, psychosomatic symptoms and family characteristics of 55 shunted hydrocephalic children older than four years were studied. Hydrocephalic childrens' self-concept, measured by the Children's Appereception Test, was found to be very significantly poorer than that of the control children. They also frequently showed behaviour disorders of the MBD-type, e.g. concentration difficulties, aggressiveness, fastidious eating and nervousness. The hydrocephalic childrens' families showed very significantly more cohesion and less rigidity, and significantly less authoritarianism than average Finnish families. When examining the parents' attitudes to their sick child, one third of the children were seen to be in a healthy role, with parental expectations realistically related to the child's abilities. One third of the children were seen as "babies", with unnecessarily over-protective attitudes on the part of their parents, and one third as "scapegoats", with accusatory attitudes from their mother and father. Those in the role of "scapegoats" had the poorest perceptual skills, the highest frequencies of behaviour disorders and the poorest self-concept.

Memory function of children with spina bifida and shunted hydrocephalus.

A group of 10 children with spina bifida and shunted hydrocephalus, aged between 7 1/2 and nine years, was tested for memory of two types of verbal material and two types of pictorial material. Their performance was compared with a group of children with matched IQ and with a group of average IQ, all matched for age and sex. The parameters investigated were learning ability; immediate and delayed recall, and also long-term recall/recognition; and reacquisition of material learned after a period of 24 hours. The hydrocephalic children and the matched IQ group were significantly poorer than the average IQ group on all tasks except for 'Memory for a Short Story' Comparisons between the hydrocephalic and matched IQ groups showed that the former group was significantly poorer only in a 'Memory for Words' test. It is suggested that this discrepancy in the performance of hydrocephalic children in learning unrelated, as opposed to connected, meaningful verbal material may reflect a deficit in their ability to use appropriate semantic strategies at the level of encoding.