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Predictors and causes of 30-day failure after shunt placement in pediatric hydrocephalus: a systematic review and meta-analysis.

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Title: Predictors and causes of 30-day failure after shunt placement in pediatric hydrocephalus: a systematic review and meta-analysis.
Authors: Di Cosmo L; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy. leonardo.dicosmo@st.hunimed.eu., Imbrogno CP; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy., El Choueiri J; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy., Nantes A; Department of Medicine, State University of Pará, Belém, Brazil., Sahgal JV; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy., Totis F; Departments of Neurological and Orthopaedic Surgery, Duke Medical Center, Duke University School of Medicine, Durham, NC, USA., Zaed I; Department of Neurosurgery, Neurocenter of South Switzerland, EOC, Lugano, Switzerland.; Department of NESMOS, Sapienza University, Rome, Italy., Jeelani NUO; Department of Pediatric Neurosurgery, Great Ormond Street Hospital, London, UK.
Source: Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery [Childs Nerv Syst] 2026 Oct 03; Vol. 42 (1). Date of Electronic Publication: 2026 Oct 03.
Publication Type: Journal Article; Systematic Review; Meta-Analysis
Language: English
Journal Info: Publisher: Springer International Country of Publication: Germany NLM ID: 8503227 Publication Model: Electronic Cited Medium: Internet ISSN: 1433-0350 (Electronic) Linking ISSN: 02567040 NLM ISO Abbreviation: Childs Nerv Syst Subsets: MEDLINE
Imprint Name(s): Original Publication: Berlin : Springer International, c1985-
MeSH Terms: Hydrocephalus*/surgery , Ventriculoperitoneal Shunt*/adverse effects , Ventriculoperitoneal Shunt*/trends , Postoperative Complications*/etiology , Postoperative Complications*/epidemiology , Equipment Failure*, Humans ; Child ; Risk Factors ; Treatment Failure
Abstract: Background: Ventriculoperitoneal (VP) shunting is the most common long-term treatment for pediatric hydrocephalus; however, early shunt failure remains a significant cause of morbidity and economic burden. Although individual studies have investigated risk factors for early failure, findings are fragmented and inconsistent. This meta-analysis evaluates the prevalence, predictors, and causes of 30-day VP shunt failure in pediatric patients.
Methods: Following PRISMA guidelines, databases were searched through November 2025 for studies reporting 30-day VP shunt failure in pediatric cohorts. Randomized controlled trials, prospective, and retrospective studies were included. Random-effects models were used, with risk ratios (RR) calculated for dichotomous outcomes and pooled prevalence estimated using generalized linear mixed models.
Results: Our analysis included 11,596 pediatric patients, with one randomized trial and 8 observational studies. The pooled prevalence of 30-day shunt failure was 13.8% (95% CI 11.2-16.8), with significantly lower rates following primary compared with secondary shunt insertion (12.6% vs 18.0%). A separate comparative analysis confirmed this reduced risk of early failure after primary insertion (RR 0.58, 95% CI 0.49-0.69; p < 0.001). When pooled female sex was associated with decreased risk of early failure, while no hydrocephalus etiology demonstrated a significant effect. Poor ventricular catheter placement was the only modifiable predictor associated with increased risk of early failure from the pooled analyses (RR 1.64, 95% CI 1.08-2.50; p = 0.02); however, this association was based on only two studies and lost significance in leave-one-out analyses. Cause-specific failure mechanisms were poorly reported across studies. Among studies reporting these outcomes, proximal catheter obstruction and malposition were the most frequently reported mechanisms of early shunt failure, followed by shunt infection. Several additional predictors were significant in individual studies and were qualitatively reported, but could not be pooled due to heterogeneous reporting.
Conclusion: VP shunt failure affects approximately one in eight pediatric patients in the first 30 days following placement, and occurs significantly more frequently following secondary shunt insertion. Among the pooled predictors, ventricular catheter placement quality represents the most significant modifiable factor associated with early shunt survival, although this finding was based on limited data. Several predictors showed estimates suggestive of increased risk; however, prospective studies with standardized reporting are necessary to define the size of these associations.
Systematic Review Registration: PROSPERO CRD420261305777.
(© 2026. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)
Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Conflict of interest: The authors declare no competing interests.
References: J Neurosurg Pediatr. 2020 Dec 18;27(3):269-276. (PMID: 33338996)
J Neurosurg Pediatr. 2011 Jul;8(1):22-9. (PMID: 21721884)
Pediatr Neurosurg. 2017;52(1):6-12. (PMID: 27490129)
J Neurosurg Pediatr. 2021 Oct 08;29(1):21-30. (PMID: 34624850)
J Neurosurg Pediatr. 2020 Dec 18;27(3):277-286. (PMID: 33338993)
Cureus. 2025 Dec 7;17(12):e98668. (PMID: 41510402)
Childs Nerv Syst. 2025 Oct 18;41(1):316. (PMID: 41109914)
Neurosurgery. 2015 Sep;77(3):321-31; discussion 331. (PMID: 26103441)
Neurosurgery. 2005;56(1):139-44; discussion 144-5. (PMID: 15617596)
World Neurosurg. 2022 Nov;167:e10-e18. (PMID: 35643406)
J Neurosurg Pediatr. 2013 Jan;11(1):15-9. (PMID: 23101557)
J Neurosurg Pediatr. 2009 Aug;4(2):156-65. (PMID: 19645551)
Childs Nerv Syst. 2007 Mar;23(3):289-95. (PMID: 17106749)
J Neurosurg. 2018 Mar 9;130(1):145-153. (PMID: 29521592)
Childs Nerv Syst. 2024 Sep;40(9):2871-2881. (PMID: 38780622)
J Neurosurg Pediatr. 2014 Aug;14(2):179-83. (PMID: 24926972)
J Neurosurg. 2000 Jan;92(1):31-8. (PMID: 10616079)
Res Synth Methods. 2021 Jan;12(1):55-61. (PMID: 32336025)
BMJ. 2016 Oct 12;355:i4919. (PMID: 27733354)
J Neurosurg Pediatr. 2014 May;13(5):525-31. (PMID: 24628507)
Pediatr Neurosurg. 1995;23(5):254-8; discussion 259. (PMID: 8688350)
Surg Neurol Int. 2015 Feb 13;6:25. (PMID: 25722930)
J Neurosurg Pediatr. 2014 Nov;14 Suppl 1:53-9. (PMID: 25988783)
World Neurosurg. 2019 Apr;124:e517-e526. (PMID: 30611949)
J Neurosurg. 2010 Dec;113(6):1273-8. (PMID: 20397892)
BMJ. 2019 Aug 28;366:l4898. (PMID: 31462531)
J Neurosurg. 2022 Dec 09;139(2):502-511. (PMID: 36681977)
J Neurosurg. 2018 Apr 27;130(4):1065-1079. (PMID: 29701543)
Neurosurgery. 1998 Aug;43(2):294-303; discussion 303-5. (PMID: 9696082)
Pediatr Infect Dis J. 2001 Jun;20(6):593-7. (PMID: 11419501)
Childs Nerv Syst. 2023 Dec;39(12):3445-3455. (PMID: 37284980)
Br J Neurosurg. 2019 Jun;33(3):357-359. (PMID: 30732482)
Surg Neurol Int. 2021 Aug 24;12:419. (PMID: 34513183)
Neurosurgery. 2014 Jan;74(1):29-34. (PMID: 24089046)
J Neurosurg Pediatr. 2008 Jan;1(1):40-7. (PMID: 18352802)
J Neurosurg. 2004 Feb;100(2 Suppl Pediatrics):90-7. (PMID: 14758935)
Contributed Indexing: Keywords: Early shunt revision; Pediatric hydrocephalus; Risk factors; Shunt failure; Ventriculoperitoneal shunt
Entry Date(s): Date Created: 20261003 Date Completed: 20261003 Latest Revision: 20261009
Update Code: 20261009
DOI: 10.1007/s00381-026-07487-3
PMID: 42829386
Database: MEDLINE
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  Data: Predictors and causes of 30-day failure after shunt placement in pediatric hydrocephalus: a systematic review and meta-analysis.
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  Data: &lt;searchLink fieldCode=&quot;AU&quot; term=&quot;%22Di+Cosmo+L%22&quot;&gt;Di Cosmo L&lt;/searchLink&gt;; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy. leonardo.dicosmo@st.hunimed.eu.&lt;br /&gt;&lt;searchLink fieldCode=&quot;AU&quot; term=&quot;%22Imbrogno+CP%22&quot;&gt;Imbrogno CP&lt;/searchLink&gt;; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.&lt;br /&gt;&lt;searchLink fieldCode=&quot;AU&quot; term=&quot;%22El+Choueiri+J%22&quot;&gt;El Choueiri J&lt;/searchLink&gt;; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.&lt;br /&gt;&lt;searchLink fieldCode=&quot;AU&quot; term=&quot;%22Nantes+A%22&quot;&gt;Nantes A&lt;/searchLink&gt;; Department of Medicine, State University of Par&#225;, Bel&#233;m, Brazil.&lt;br /&gt;&lt;searchLink fieldCode=&quot;AU&quot; term=&quot;%22Sahgal+JV%22&quot;&gt;Sahgal JV&lt;/searchLink&gt;; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.&lt;br /&gt;&lt;searchLink fieldCode=&quot;AU&quot; term=&quot;%22Totis+F%22&quot;&gt;Totis F&lt;/searchLink&gt;; Departments of Neurological and Orthopaedic Surgery, Duke Medical Center, Duke University School of Medicine, Durham, NC, USA.&lt;br /&gt;&lt;searchLink fieldCode=&quot;AU&quot; term=&quot;%22Zaed+I%22&quot;&gt;Zaed I&lt;/searchLink&gt;; Department of Neurosurgery, Neurocenter of South Switzerland, EOC, Lugano, Switzerland.; Department of NESMOS, Sapienza University, Rome, Italy.&lt;br /&gt;&lt;searchLink fieldCode=&quot;AU&quot; term=&quot;%22Jeelani+NUO%22&quot;&gt;Jeelani NUO&lt;/searchLink&gt;; Department of Pediatric Neurosurgery, Great Ormond Street Hospital, London, UK.
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– Name: Abstract
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  Data: Background: Ventriculoperitoneal (VP) shunting is the most common long-term treatment for pediatric hydrocephalus; however, early shunt failure remains a significant cause of morbidity and economic burden. Although individual studies have investigated risk factors for early failure, findings are fragmented and inconsistent. This meta-analysis evaluates the prevalence, predictors, and causes of 30-day VP shunt failure in pediatric patients.&lt;br /&gt;Methods: Following PRISMA guidelines, databases were searched through November 2025 for studies reporting 30-day VP shunt failure in pediatric cohorts. Randomized controlled trials, prospective, and retrospective studies were included. Random-effects models were used, with risk ratios (RR) calculated for dichotomous outcomes and pooled prevalence estimated using generalized linear mixed models.&lt;br /&gt;Results: Our analysis included 11,596 pediatric patients, with one randomized trial and 8 observational studies. The pooled prevalence of 30-day shunt failure was 13.8% (95% CI 11.2-16.8), with significantly lower rates following primary compared with secondary shunt insertion (12.6% vs 18.0%). A separate comparative analysis confirmed this reduced risk of early failure after primary insertion (RR 0.58, 95% CI 0.49-0.69; p &amp;lt; 0.001). When pooled female sex was associated with decreased risk of early failure, while no hydrocephalus etiology demonstrated a significant effect. Poor ventricular catheter placement was the only modifiable predictor associated with increased risk of early failure from the pooled analyses (RR 1.64, 95% CI 1.08-2.50; p = 0.02); however, this association was based on only two studies and lost significance in leave-one-out analyses. Cause-specific failure mechanisms were poorly reported across studies. Among studies reporting these outcomes, proximal catheter obstruction and malposition were the most frequently reported mechanisms of early shunt failure, followed by shunt infection. Several additional predictors were significant in individual studies and were qualitatively reported, but could not be pooled due to heterogeneous reporting.&lt;br /&gt;Conclusion: VP shunt failure affects approximately one in eight pediatric patients in the first 30&#160;days following placement, and occurs significantly more frequently following secondary shunt insertion. Among the pooled predictors, ventricular catheter placement quality represents the most significant modifiable factor associated with early shunt survival, although this finding was based on limited data. Several predictors showed estimates suggestive of increased risk; however, prospective studies with standardized reporting are necessary to define the size of these associations.&lt;br /&gt;Systematic Review Registration: PROSPERO CRD420261305777.&lt;br /&gt; (&#169; 2026. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)
– Name: Abstract
  Label: Competing Interests
  Group: Ab
  Data: Declarations. Ethics approval and consent to participate: Not applicable. Conflict of interest: The authors declare no competing interests.
– Name: Ref
  Label: References
  Group: RefInfo
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  Data: &lt;i&gt;Keywords: &lt;/i&gt;Early shunt revision; Pediatric hydrocephalus; Risk factors; Shunt failure; Ventriculoperitoneal shunt
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    Subjects:
      – SubjectFull: Humans
        Type: general
      – SubjectFull: Child
        Type: general
      – SubjectFull: Risk Factors
        Type: general
      – SubjectFull: Treatment Failure
        Type: general
      – SubjectFull: Hydrocephalus surgery
        Type: general
      – SubjectFull: Ventriculoperitoneal Shunt adverse effects
        Type: general
      – SubjectFull: Ventriculoperitoneal Shunt trends
        Type: general
      – SubjectFull: Postoperative Complications etiology
        Type: general
      – SubjectFull: Postoperative Complications epidemiology
        Type: general
      – SubjectFull: Equipment Failure
        Type: general
    Titles:
      – TitleFull: Predictors and causes of 30-day failure after shunt placement in pediatric hydrocephalus: a systematic review and meta-analysis.
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Di Cosmo L
      – PersonEntity:
          Name:
            NameFull: Imbrogno CP
      – PersonEntity:
          Name:
            NameFull: El Choueiri J
      – PersonEntity:
          Name:
            NameFull: Nantes A
      – PersonEntity:
          Name:
            NameFull: Sahgal JV
      – PersonEntity:
          Name:
            NameFull: Totis F
      – PersonEntity:
          Name:
            NameFull: Zaed I
      – PersonEntity:
          Name:
            NameFull: Jeelani NUO
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 03
              M: 10
              Text: 2026 Oct 03
              Type: published
              Y: 2026
          Identifiers:
            – Type: issn-electronic
              Value: 1433-0350
          Numbering:
            – Type: volume
              Value: 42
            – Type: issue
              Value: 1
          Titles:
            – TitleFull: Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery
              Type: main
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