Discussion
failure of the primary, drowsiness, hydrocephalus, vomiting, obstruction by the choroid plexus, headache, lower obstruction rate
HYDROCEPHALUS, COMPLICATION, WHITEHEAD, SHUNT INFECTION, COMPLICATIONS
The placement of a ventriculo-peritoneal shunt is the current standard in the treatment of hydrocephalus in spite of high complication rates [Concerning operative complications during the first postoperative month between ultrasound-guided and conventional groups, our results revealed that there were no significant differences between groups, but proximal obstruction which is the commonest complication occurred only in the conventional group (3 cases 10%).It is believed that obstruction by the choroid plexus is the most common reason for the failure of the cranial catheter of the ventriculoperitoneal shunt [The results of the present study agree with several studies which concluded that shunt catheter obstructions either proximal or distal obstruction are by far the most common cause of shunt malfunction, yet the factors that contribute to this matter remain elusive. Obstruction can occur in the proximal catheter itself or within the valve or within the distal catheter; however, the commonest site of obstruction in most studies is the proximal tube [In contrast to our results, Whitehead et al. [In our study, the intraoperative ultrasound image of the ventricular catheter was obtained while passing through the body of the lateral ventricle with the stylet in place, and if we decided to continue to the frontal horn, we must identify the choroid plexus which appears hyper-echogenic bilaterally and then by tilting the transducer from the coronal plan, we find the pathway to the frontal horn and then advance the tube to the required location and finally remove the stylet; we also take sagittal ultrasound images for confirmation as shown in image 1. After this maneuver, the catheter was attached to the valve.The use of ultrasound does not cause prolongation or complication of the procedure as the operation time is not prolonged, no risk factor regarding shunt infection. It is accurate as frameless navigation insertion and due to its precise location, there are lower obstruction rate [Our results showed no significant difference between groups regarding follow-up imagining data within the first postoperative 48 ho and after 3 months from surgery except for ventricular tube location in favor of the ultrasound group (Our results showed that 3 patients from the conventional group needed revisions at the cranial end. There were 2 cases that needed revisions at the peritoneal end in the ultrasound-guided group and one case in the conventional group.Stone et al. [Ventriculoperitoneal shunts are associated with a high rate of malfunction; one study reported revision rates of 32.5% in adults which was significantly higher (78.2%) in children [In our study, the complicated cases with shunt obstructions which operated again for shunt revisions had been excluded in the follow-up as considered failure of the primary aim.In general, children with shunt malfunction may be present with the symptoms of headache, vomiting, and drowsiness, but at these young ages, the symptoms can represent many other illnesses [A study showed that 25.3% of all CT scans were performed in children less than 2 years of age, suggesting bad radiation exposure could potentially be reduced by clinical assessment and the use of diagnostic scales [Regarding shunt infection in our study, there were no significant differences between the groups with an overall rate of 6.7%, and all were treated by conservative treatment. Bastian et al. [