PATTERNS AND MECHANISMS OF VENTRICULOPERITONEAL SHUNT MALFUNCTION ACCORDING TO PROXIMAL VENTRICULAR CATHETER ENTRY POINT IN CHILDREN: A SCOPING REVIEW
Keywords:
pediatric hydrocephalus, ventriculoperitoneal shunt, catheter entry point, proximal obstruction, malfunction mechanismAbstract
Introduction: Ventriculoperitoneal shunt (VPS) is the most common cerebrospinal fluid diversion procedure in pediatric hydrocephalus, yet it is the most failure-prone device. The proximal ventricular catheter is the dominant weak point, and the cranial entry point is a determinant entirely under the surgeon's control. This review maps the patterns and mechanisms of VPS malfunction according to proximal catheter entry point in children.
Methods: This scoping review followed JBI methodology and PRISMA-ScR reporting. Systematic searches were conducted in PubMed, ClinicalTrials.gov, Semantic Scholar, Elsevier, and Cochrane (2016–2026). Inclusion criteria comprised children <18 years with hydrocephalus undergoing primary or revision VPS, with entry point reported or proximal catheter mechanism studied. Two reviewers independently performed selection and data charting. Risk of bias was assessed using RoB 2, ROBINS-I, and ROBINS-E.
Results: Twenty-seven reports (2 RCTs, 25 non-randomized; >12,000 children; ≥379 explanted catheters) were analyzed. Pooled cohort analysis showed an advantage for anterior entry (HR 0.68; 95% CI 0.56–0.83; I²=0%), although the HCRN RCT was non-significant (p=0.062). Proximal obstruction was less frequent with frontal entry (RR 0.16; 95% CI 0.05–0.57). Key mechanisms included ventricular wall and choroid plexus contact (p=0.005), distinct hole-occlusion patterns with parietal entry (p=0.001), and a universal, time-dependent microglia-to-astrocyte transition. Catheter migration was documented only with the frontal route in children <3 years, associated with non-burr-hole valves and right-angle adaptors. Age <6 months was the strongest risk modifier (HR 1.49; 95% CI 1.28–1.73). Image guidance improved accuracy (RR 0.41; 95% CI 0.21–0.78).
Discussion: The anterior advantage is modest and time-dependent, mediated primarily by tip environment and proximal obstruction rather than infection. Specific vulnerabilities of the anterior route in neonates and infants include trajectory error and migration, which are technically preventable. Only one quarter of the literature stratifies outcomes by entry site.
Conclusion: Proximal catheter entry point is a modifiable determinant of pediatric VPS malfunction. The anterior route is recommended as the default for first-time pediatric VPS, with age-specific risk mitigation through image guidance, cranial inclination control, and burr-hole valve or straight connector anchoring.
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