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 J Neurosurg Pediatrics 10:327–333, 2012

Electromagnetic-guided neuronavigation for safe placement

of intraventricular catheters in pediatric neurosurgery
Clinical article

Elvis J. Hermann, M.D., Hans-Holger Capelle, M.D., Christoph A. Tschan, M.D.,

and Joachim K. Krauss, M.D.

Department of Neurosurgery, Medical School Hannover, Germany

Object. Ventricular catheter shunt malfunction is the most common reason for shunt revision. Optimal ventricu-
lar catheter placement can be exceedingly difficult in patients with small ventricles or abnormal ventricular anatomy.
Particularly in children and in premature infants with small head size, satisfactory positioning of the ventricular
catheter can be a challenge. Navigation with electromagnetic tracking technology is an attractive and innovative
therapeutic option. In this study, the authors demonstrate the advantages of using this technology for shunt placement
in children.
Methods. Twenty-six children ranging in age from 4 days to 14 years (mean 3.8 years) with hydrocephalus and
difficult ventricular anatomy or slit ventricles underwent electromagnetic-guided neuronavigated intraventricular
catheter placement in a total of 29 procedures.
Results. The single-coil technology allows one to use flexible instruments, in this case the ventricular catheter
stylet, to be tracked at the tip. Head movement during the operative procedure is possible without loss of navigation
precision. The intraoperative catheter placement documented by screenshots correlated exactly with the position on
the postoperative CT scan. There was no need for repeated ventricular punctures. There were no operative complica-
tions. Postoperatively, all children had accurate shunt placement. The overall shunt failure rate in our group was 15%,
including 3 shunt infections (after 1 month, 5 months, and 10 months) requiring operative revision and 1 distal shunt
failure. There were no proximal shunt malfunctions during follow-up (mean 23.5 months).
Conclusions. The electromagnetic-guided neuronavigation system enables safe and optimal catheter placement,
especially in children and premature infants, alleviating the need for repeated cannulation attempts for ventricular
puncture. In contrast to stereotactic techniques and conventional neuronavigation, there is no need for sharp head
fixation using a Mayfield clamp. This technique may present the possibility of reducing proximal shunt failure rates
and costs for hydrocephalus treatment in this age cohort.
(http://thejns.org/doi/abs/10.3171/2012.7.PEDS11369)

Key Words      •      electromagnetic-guided neuronavigation      •      hydrocephalus      •      shunt

C
erebrospinal fluid diversion by implantation of
a shunt system for treatment of hydrocephalus
is one of the most common neurosurgical proce-
dures.5,13,17,21,23,26 Since the basic systems were introduced
as part of the clinical routine more than 40 years ago,
numerous technical improvements have resulted in in-
creased safety and efficacy.16,19,32–34,36 Nevertheless, shunt
dysfunction remains a significant cause of secondary
morbidity, in particular in infants and children.22,25 One
frequent cause of shunt dysfunction is obstruction of
the proximal catheter, which has been shown to be of-
ten associated with suboptimal catheter placement.8,14,15
Ventricular catheters are usually inserted with a freehand
technique using anatomical landmarks. However, it has
been shown that inaccuracies of the catheter location oc-
cur in more than 22% of patients when using this tech-
nique.12 The failure rate of introducing a ventricular cath-
eter on the first attempt in patients with narrow ventricles
may be as high as 68%.18 Therefore, several techniques
were developed to improve catheter placement, including
ultrasonography-guided, frame-based stereotactic, and
frameless navigation techniques.1,16 Whereas frameless
techniques continue to require rigid fixation of the head,
electromagnetic-guided neuronavigation—a relatively
new technique—obviates this problem.11 Electromagnet-
ic-guided neuronavigation also has several other advan-
tages that make it a suitable method for the placement of
shunt systems.6,9,10
We have previously shown the feasibility of this tech-
nique in adults with hydrocephalus,28 but there is very
limited experience with this technique in children.6,10,31 In
this paper, we demonstrate its usefulness in the pediatric
This article contains some figures that are displayed in color
on­line but in black-and-white in the print edition.

J Neurosurg: Pediatrics / Volume 10 / October 2012 327


age group, addressing the specific issues in this vulner-
able patient population. In contrast to a previous study,6
we also included infants and newborns in this study, and
we provide longer follow-up periods.
Methods
From a total of 85 shunt insertions in the pediatric
age group during the study period, 26 patients underwent
shunt placement using electromagnetic-guided neuronav-
igation. We prospectively collected data on these 26 chil-
dren who underwent electromagnetic-guided placement
of a ventricular catheter between April 2009 and October
2010 at the Department of Neurosurgery, Medical School
Hannover, Germany. Selection criteria for patients in this
study were especially slit or dysmorphic ventricles and
preterm infants with very small head size. In all patients,
optimal freehand placement of a ventricle catheter was
believed to be difficult, and therefore electromagnetic-
guided neuronavigation was used. A total of 29 navigated
procedures were performed, including 3 reoperations af-
ter temporary shunt removal because of infection. There
were 15 boys and 11 girls included in the analysis, whose
ages ranged from 4 days to 14 years (mean 3.8 years; Ta-
ble 1).
Patient Characteristics
To be included in this study, children aged 0 to 14
years had to have small or dysmorphic ventricles, which
were believed to be difficult to cannulate by a freehand
method. Twelve of 26 shunt-dependent children had
growth-related dislocation of the ventricular catheter and
narrow ventricles (Table 1).
Posthemorrhagic hydrocephalus of the premature
newborn with a very small head size was present in 5 of
26 cases, and congenital hydrocephalus was present in 8
of 26 cases, which was associated with lumbosacral my-
elomeningocele (n = 3), Dandy Walker complex (n = 1),
aqueductal stenosis (n = 2, including 1 relapse after ven-
triculocisternostomy), and unknown origin (n = 2). Other
disorders included isolated fourth ventricle in preterm in-
fants (2/26) and hydrocephalus with asymmetric enlarge-
ment of the occipital horn (1/26). Furthermore, Ommaya
reservoirs were placed in 3 children with malignant brain
tumors and meningeal carcinomatosis to facilitate intra-
thecal chemotherapy (Table 1).
Data were collected prospectively and included an
imaging procedure protocol, specification of the number
of passes to cannulate the ventricle, documentation of in-
traoperative screenshots, recording of complications, and
follow-up for at least 11 months. A summary of the clini-
cal and follow-up data are provided in Table 1.
Technical Specifications of the Electromagnetic-Guided
System
For electromagnetic-guided neuronavigation the
AxiEM neuronavigation system (Medtronic) was used,
which consists of several components as previously de-
scribed in detail in an earlier study from our group.28 The
system works at a field strength of 100 A/m at 50 mm
off-face of the transmitter coil array, decreased by 1/r3
328
E. J. Hermann et al.
(Norm IEC 61000–4-8). The field of the emitter is be-
tween 0 and 3.57 Gauss over the working volume (earth
magnetic field approximately 1 Gauss). The “usable field”
covers a roughly cubic-shaped area of 650 × 525 mm. In
contrast to our earlier study, we did not use fiducials fixed
to the osseous skull, but instead used surface rendering of
the face in all individuals.
Electromagnetic-Guided Surgery
Preoperatively, all children underwent CT (n = 26)
and additional MRI (n = 8) under local or general an-
esthesia. For 3D reconstruction, a workstation was used
(Stealth Station, Medtronic Navigation). In the operating
room, the dynamic reference frame was attached to the
child’s forehead by adhesive tape on the opposite side
of the planned surgery. The transmitter coil was fixed to
the table on the side where the dynamic reference frame
was attached. Intraoperative registration was achieved
by surface matching over the facial surface. Thereafter,
registration was achieved by automatic computing of a
correlation matrix.
Before starting surgery, confirmation of accuracy
was achieved by checking for deviations of the position
of the tragus, bregma, and nasion. Patient position dur-
ing surgery was changed as deemed necessary, even from
supine to prone for cannulating the fourth ventricle with-
out a new registration procedure. After planning of the
trajectory and the entry point, routine sterile draping was
performed. The target point for the tip of the ventricu-
lar catheter was chosen individually in each case, avoid-
ing the choroid plexus and placing the catheter tip in the
center of the frontal horn where most CSF was visible
close to the foramen of Monro. During cannulation of the
ventricle, online tracking of the catheter tip, containing
a stylet with a coil in its tip, enabled accurate position-
ing of the catheter under direct observation on the screen.
Screenshots for offline comparison with postoperative
CT scans were obtained with the stylet inside the catheter
at the predetermined position of the catheter tip. The head
of the patient was freely movable during all of the proce-
dures. Tunneling and placement of the peritoneal catheter
was performed without removal of the navigation system.
Postoperative Imaging
Postoperative CT scans were obtained within 2 days
after surgery to rule out complications and to check the
position of the catheter tip.
Results
Fourteen children (53.8%) were younger than 2 years
and 9 children (34.6%) were younger than 1 year at the
time of the first operation. In 2 children, 2 ventricular
catheters were navigated during the same operation: Case
9, bilateral catheter placement in a child with distorted
ventricular anatomy due to a huge optic glioma; and Case
20, ventricular catheter placement in the frontal horn and
in a trapped fourth ventricle in a child with growth-re-
lated dislocation of catheters in posthemorrhagic hydro-
cephalus.
Accuracy of registration was within 2 mm in all cas-
J Neurosurg: Pediatrics / Volume 10 / October 2012
Electromagnetic navigation of ventricular catheters in children

TABLE 1: Characteristics of children who underwent operations using electromagnetic-guided neuronavigation over a 1.5-year period*

Age at
Case Op (mos), Follow-Up
No. Sex Cause of Hydrocephalus Indication for Neuronavigation (mos) Complications
 1 21, M posthemorrhagic, preterm elective revision of growth-related dislocation of 37 none
  the ventricular catheter, slit ventricles
 2 20, M spina bifida elective revision of growth-related dislocation of 37 shunt explantation due to shunt in-
  the ventricular catheter, slit ventricles   fection 1 mo after op, reinsertion
  of shunt
 3 54, F congenital aqueductal stenosis elective revision of growth-related dislocation of 37 none
  the ventricular catheter, slit ventricles
 4 0, F spina bifida placement of an occipital ventricular catheter in 35 shunt explantation due to shunt in-
  dysmorphic ventricles   fection 5 mos after op, reinser-
  tion of shunt
 5 168, M posthemorrhagic, preterm elective revision of growth-related dislocation of 34 none
  the ventricular catheter, slit ventricles
 6 2, M posthemorrhagic, preterm trapped 4th ventricle 33 shunt explantation due to shunt in-
  fection 10 mos after op, reinser-
  tion of shunt
 7 168, M medulloblastoma, meningeal Ommaya reservoir for intraventricular chemo- 33 none
 carcinomatosis  therapy
 8 60, M posthemorrhagic, preterm elective revision of growth-related dislocation of 32 none
  the ventricular catheter, slit ventricles
 9 16, F optic glioma, occlusive distorted ventricular anatomy (bifrontal) 32 none
10 96, M posthemorrhagic, preterm elective revision of growth-related dislocation of 30 none
  the ventricular catheter, slit ventricles
11 26, F posthemorrhagic, preterm very small head size due to preterm birth 30 none
12 25, M congenital elective revision of growth-related dislocation of 23 none
  the ventricular catheter, slit ventricles
13 3, F posthemorrhagic, preterm very small head size due to preterm birth 23 none
14 4, F Dandy-Walker syndrome asymmetric ventricles, distorted anatomy 22 none
15 43, F congenital distorted anatomy 20 shunt dysfunction due to ascites
  at 1 mo follow-up, conversion of
  ventriculoperitoneal shunt into
  ventriculoatrial shunt
16 2, M posthemorrhagic, preterm very small head size due to preterm birth 18 none
17 8, F congenital aqueductal stenosis slit ventricles, recurrence of aqueductal stenosis 18 none
  after ventriculocisternostomy
18 13, F posthemorrhagic, preterm elective revision of growth-related dislocation of 17 none
  the ventricular catheter, slit ventricles
19 2, M posthemorrhagic, preterm very small head size due to preterm birth 17 none
20 144, M posthemorrhagic, preterm elective revision of growth-related dislocation of 13 none
  the ventricular catheter in a trapped 4th
 ventricle
21 16, M posthemorrhagic, preterm elective revision of growth-related dislocation of 13 none
  the ventricular catheter, slit ventricles
22 168, F spina bifida elective revision of growth-related dislocation of 12 none
  the ventricular catheter, slit ventricles
23 40, M glioblastoma, meningeal car- Ommaya reservoir for intraventricular chemo- 11 none
 cinomatosis  therapy
24 3, M anaplastic astrocytoma, men- Ommaya reservoir for intraventricular chemo- 11 none
  ingeal carcinomatosis  therapy
25 2, M posthemorrhagic, preterm very small head size due to preterm birth 11 none
26 84, F posthemorrhagic, preterm elective revision of growth-related dislocation of 11 none
  the ventricular catheter, slit ventricles

*  All patients underwent only 1 pass to cannulate the ventricles.

J Neurosurg: Pediatrics / Volume 10 / October 2012 329


es as determined by checking the positions for the tragus,
nasion, and bregma. The time for installation of the sys-
tem and for registration added 10 minutes on average.
No line-of-sight problems and no restriction of head
movements were noted. Even completely turning the pa-
tient, as shown in the case illustrations below, was pos-
sible without loss of navigational accuracy. Interferences
with metallic instruments such as wound retractors were
detected in some instances, but this did not result in lo-
calizing errors. In these cases, the retractor had to be re-
moved at the time of ventricular cannulation. Tunneling
and placement of the peritoneal shunt catheter was pos-
sible without disturbance by the navigation system in all
instances.
Safe and accurate placement of the ventricular cath-
eter was achieved in all instances. In each instance only
a single cannulation was necessary for accurate place-
ment of the catheter. No immediate complications such
as hematoma or shunt dysfunction occurred. All catheters
were placed precisely at the predetermined position ac-
cording to the intraoperative screenshot. Concordance
of the screenshots and the postoperative CT scans were
demonstrated in all cases.
Follow-up ranged from 11 to 37 months (mean 23.5
months). No mechanical obstruction of the ventricular
catheter was observed during follow-up. Three shunt in-
fections occurred within the first year after the operation
(1 month, 5 months, and 10 months after shunt insertion)
in 2 newborns with myelomeningocele (Cases 2 and 4)
and in 1 preterm infant with posthemorrhagic hydro-
cephalus (Case 6). In 1 of the patients who had a catheter
placed in the occipital horn (Case 4), a wound-healing
problem occurred due to the pressure on the wound by
lying on it, with the need for revision. All of these 3 chil-
dren were younger than 2 years.
In 1 patient with congenital hydrocephalus (Case 15),
ascites occurred after 1 month of follow-up, and a con-
version of the distal catheter of the ventriculoperitoneal
shunt into a ventriculoatrial shunt was necessary. Thus,
the overall shunt failure rate in our group was 15.4%, in-
cluding 3 shunt infections (11.5%) and 1 distal shunt fail-
ure (3.9%).
Illustrative Cases
Case 1
This 21-month-old boy with growth-related disloca-
tion of the ventricular catheter was scheduled to undergo
elective shunt revision (Fig. 1A and B). Hydrocephalus
was associated with a posthemorrhagic preterm. Figure
1C shows the postoperative CT scan of the head with sat-
isfactory position of the tip of the new ventricular catheter
close to the foramen of Monro. The patient is doing well
after a follow-up of 37 months.
Case 6
This 2-month-old preterm infant with posthemor-
rhagic hydrocephalus and an isolated fourth ventricle
secondary to postpartum intracerebral and intraventric-
ular bleeding was referred for shunt surgery. There was
330
E. J. Hermann et al.
progressive dilatation of the fourth ventricle for 1 week,
and it was decided to place a Rickham reservoir into the
trapped fourth ventricle for CSF diversion guided by elec-
tromagnetic neuronavigation. Preoperatively, 3D CT and
MRI of the head were performed under general anesthe-
sia. Figure 2A shows a preoperative sagittal T2-weighted
MR image. After surface registration of the patient’s face
to the MRI data in the supine position (Fig. 2B), body
position was changed to prone for the procedure without
accuracy loss for the navigation procedure (Fig. 2C). Af-
ter planning the trajectory, the cannulation of the trapped
fourth ventricle was performed without complications.
Next, tunneling and placement of the peritoneal catheter
was performed. Figure 2D shows a CT scan obtained
postoperatively with appropriate positioning of the cath-
eter in the fourth ventricle.
Discussion
Electromagnetic-guided neuronavigation is an el-
egant new technique that has recently been called a
revolution in image-guided neurosurgery.11 Nevertheless,
although it has been available for almost 10 years, the
number of publications demonstrating its use are limited,
and it still has not found widespread acceptance. With
the present study, we extend earlier limited experience
with this technique for placement of ventricular cath-
eters,2,3,6,10,11,20 demonstrating its usefulness in a selected
population of difficult-to-shunt children with hydroceph-
alus. Cannulation of ventricles was possible with the first
pass in all instances, and remarkably, the need for shunt
revision surgery was significantly lower than expected,
except in instances of shunt infection. The infection rate
was comparable to data from the literature regarding pa-
tients in this age group (< 3 years of age), where the shunt
infection rate is higher than in older patients. In our opin-
ion, electromagnetic-guided neuronavigation does not
contribute to the infection rate.7,35
Proximal failure rates in blind catheter placement
have been reported to be as high as 35%15 and 38%.35
Proximal shunt catheter obstructions tend to occur earlier
after insertion of a shunt system than do distal obstruc-
tions and disconnections, which are more common in late
failures.24
Problems with conventional freehand ventricular
catheter placement are well known, and even in patients
with wide ventricles, blind catheter insertion may result
in suboptimal placement in a relatively high number of
patients.12 It has been shown convincingly that suboptimal
ventricular catheter placement increases the risk of long-
term shunt dysfunction. Toma et al.37 analyzed a total of
183 CT scans after insertion of a ventricular catheter us-
ing the freehand technique. The target was the center of
the frontal horn of the ipsilateral ventricle. When the tip
of the inserted ventricular catheter was outside the target,
40% of patients needed a revision, as compared with only
25% when the catheter tip was within the defined target
area.
In a study investigating the failure rates for shunt dys-
function, proximal catheter obstruction due to ingrowth
of the choroid plexus was identified as the most common
J Neurosurg: Pediatrics / Volume 10 / October 2012
Electromagnetic navigation of ventricular catheters in children

Fig. 1.  Case 1.  A and B: Preoperative axial CT scans in a 21-month-old boy showing growth-related dislocation of the
ventricular catheter. The primary cause of his hydrocephalus was a posthemorrhagic preterm.  C: Axial CT scan obtained
immediately postoperatively demonstrates precise placement of the tip of the newly implanted ventricular catheter using electro-
magnetic-guided neuronavigation.

mechanical cause.8 When different approaches for place- between 0.7–4.4 mm4 and 0.71–3.51 mm.29 In the present
ment of the ventricular catheter were compared (frontal study, we did not observe any case with localizing errors.
vs parietal) in a study population of 117 patients with an The feasibility of electromagnetic-guided neuronavi-
age range from 1 month to 80 years, no significant dif- gation to insert ventricular catheters has been shown in
ference regarding shunt dysfunction was noted. However, both adults and children.3,9,27,28 The use of electromagnet-
significantly higher malfunction rates were found in pa- ic-guided neuronavigation for slit ventricle syndrome and
tients less than 3 years of age. It was concluded that op- complex hydrocephalus was demonstrated by Clark et
timal shunt placement resulted in less shunt dysfunction, al.6 In that study, the proximal shunt failure rate was 9%,
regardless of the approach used. which was lower than reported failure rates using con-
Narrow ventricles pose a special challenge for shunt ventional techniques.15,35 Follow-up was limited, however,
surgery. Repeated attempts at cannulation may cause and children younger than 2 years were not included. In
trauma to the brain or bleeding, with the risk of devel-
oping neurological sequelae or epilepsy. Whereas shunt
dysfunction was 27% in children with normal-sized ven-
tricles and 36% in those with large ventricles, it was 44%
in those with slit ventricles in a large pediatric series.30 In
that study, 4% of ventricle catheters were even misplaced
outside of the ventricles.
Neuronavigation is an established technique in neu-
rosurgery. Although almost all systems currently use
frameless stereotactic technology, their use continues to
require rigid head fixation. Therefore, common neuro-
navigation systems using “optoelectric” principles can
be problematic in the pediatric population. In general,
sharp head fixation (fixation in the Mayfield clamp with
3 sharp pins) is avoided in infants, and it is not at all fea-
sible in preterm and newborn children. In children older
than 1 year of age, head fixation with the Mayfield clamp
involves a small but definite risk for skull fractures with
subsequent CSF leakage. Furthermore, conventional nav-
igation systems do not allow a change of head position to
tunnel the shunt catheter once the ventricular catheter has
been placed.
Flexible electromagnetic-guided neuronavigation
with a dynamic reference frame, therefore, appears to be
an ideal method for the pediatric population, in particular
for the placement of ventricular catheters. Its definite ad-
vantages are that it does not require sharp head fixation,
and that even changes of the head position during surgery Fig. 2.  Case 6.  A: Preoperative sagittal T2-weighted MR image
are possible. The accuracy of image-guided localization showing a trapped fourth ventricle in a 2-month-old preterm boy.  B:
Fixation of the dynamic reference frame and intraoperative registration
using electromagnetic guidance is similar to that reported while the boy is supine.  C: Planning of the operative procedure while
for optically guided systems. The accuracy of electromag- the boy is prone.  D: Postoperative axial CT scan demonstrates the
netic-guided neuronavigation has been reported to range inserted catheter with the tip in the enlarged fourth ventricle.

J Neurosurg: Pediatrics / Volume 10 / October 2012 331


a recent prospective multicenter study, 41 patients had
received ventricular catheters using standard techniques
and 34 using electromagnetic guidance.10 Patients with
slit ventricles were excluded. The number of catheters
placed in an optimal position in the ventricles was signifi-
cantly increased by electromagnetic guidance. Although
the overall shunt survival was not different between the
study groups, there was a marked reduction in proximal
shunt dysfunction.
The distinctive feature of our pediatric study as com-
pared with previous studies is the use of electromagnetic-
guided neuronavigation, especially in the age group un-
der 3 years and in preterm infants. Treatment of these
patients is challenging, and to reach a maximum of safety
for these children, electromagnetic-guided neuronaviga-
tion can be essential in many cases. There were no proxi-
mal shunt malfunctions during follow-up (mean 23.5
months).
In very young children with an open fontanelle and
wide ventricles, ultrasonography is a valuable tool in ex-
perienced hands to secure appropriate shunt insertion.
Unfortunately, ultrasonography has limitations in young
children with a small fontanelle and with slit ventricles
or an abnormal ventricular system. In such a context,
AxiEM navigation based on 3D images may be advanta-
geous, enabling exact positioning of the ventricular cath-
eter tip.
One important concern in the application of electro-
magnetic-guided neuronavigation in young children is
the necessity of preoperative CT or MRI. While CT scan-
ning exposes these children to additional radiation, MRI
is often not possible without sedation. Therefore, when-
ever possible, ultrasonography should be considered as
an alternative in very young children to guarantee accu-
rate placement of ventricular catheters and reduce shunt
malfunction. A future option might also be to integrate
preoperative ultrasonography directly into the navigation
system in this difficult-to-treat patient subgroup.
While postoperative CT scans were obtained in the
present study to confirm the accuracy of electromagnetic-
guided neuronavigation, our study convincingly demon-
strates that in routine clinical practice such controls are
unnecessary and should actually be abandoned to reduce
exposure to additional radiation.
A prospective multiinstitutional trial showed an over-
all shunt malfunction rate of nearly 50% at 24 months
postoperatively.16 In our series, we found an overall shunt
malfunction rate of 15.4%, but we had no malfunction of
the implanted proximal catheter up to a mean follow-up
of 23.5 months. These data appear to be promising with
regard to shunt malfunction, as well as regarding cost ef-
ficacy. One problem that cannot be addressed by consid-
erations of how to place the ventricular catheter is shunt
infection. It appears that infection rates were similar in
studies using electromagnetic guidance (including our
study) to those studies using conventional techniques re-
ported recently.7,35
Disadvantages of image-guidance techniques for
shunt surgery have been well identified.10 These disad-
vantages primarily include the need for added imaging
preoperatively (depending on the imaging protocol) and
added time for setup of the system. One specific problem
332
E. J. Hermann et al.
that electromagnetic-guided neuronavigation can solve is
the need for sharp head fixation. It remains to be deter-
mined which technology will be the future standard, and
this subject certainly requires further investigation. One
weakness of this study is that there was no control group;
therefore conclusions are limited. Randomized prospec-
tive studies are needed to address this issue.
Conclusions
Electromagnetic-guided neuronavigation is safe and
provides accurate catheter placement, both in children
and premature infants. Repeated cannulation attempts
for ventricular puncture are completely avoided with this
technique. It may reduce proximal shunt failure rates and
costs for hydrocephalus treatment in this age cohort.
Disclosure
The authors report no conflict of interest concerning the mate-
rials or methods used in this study or the findings specified in this
paper.
Author contributions to the study and manuscript preparation
include the following. Conception and design: Hermann, Krauss.
Acquisition of data: Hermann, Tschan. Analysis and interpretation
of data: Hermann, Krauss. Drafting the article: Hermann, Krauss.
Critically revising the article: all authors. Reviewed submitted
version of manuscript: all authors. Approved the final version of
the manuscript on behalf of all authors: Hermann. Statistical analy-
sis: Hermann. Administrative/technical/material support: Capelle,
Tschan. Study supervision: Krauss.
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Manuscript submitted August 30, 2011.
Accepted July 5, 2012.
Please include this information when citing this paper: pub-
lished online August 10, 2012; DOI: 10.3171/2012.7.PEDS11369.
Address correspondence to: Elvis J. Hermann, M.D., Depart-
ment of Neurosurgery, Medical School Hannover, Carl-Neuberg-
Strasse 1, 30625 Hannover, Germany. email: hermann.elvis@
mh-hannover.de.
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