Change in Optic Nerve Sheath Diameter and Cerebral Ventricular Shunt Failure in Children
Bibliographic record
Abstract
Importance: Ocular point-of-care ultrasonography (POCUS) may be a clinically useful method to evaluate shunt dysfunction for children with hydrocephalus presenting to the emergency department (ED). Objective: To evaluate whether a change in the optic nerve sheath diameter (ONSD) from prior asymptomatic baseline was associated with shunt failure. Design, Setting, and Participants: Participants in this prospective single-center observational cohort study at a tertiary care children's hospital were enrolled from January 5, 2018, to March 2, 2022. Children 18 years or younger with cerebrospinal fluid (CSF) shunts were consecutively recruited during routine asymptomatic visits in the outpatient neurosurgery clinic. The institution sees approximately 1000 children with shunts. Children with comorbid eye pathologic conditions known to increase the ONSD were excluded, as were those with shunt interventions between baseline and symptomatic ocular POCUS. Data analysis was completed in May 2024. Exposures: Baseline ocular POCUS was performed on asymptomatic children with CSF shunts recruited in the outpatient neurosurgery clinic; a second ocular POCUS was performed if the patient subsequently presented to the ED with symptoms of shunt failure. Change in ONSD from prior asymptomatic baseline to symptomatic presentation was the main study exposure. Main Outcomes and Measures: Shunt failure was defined as intraoperative confirmation of inadequate CSF flow through the shunt system associated with identifiable shunt complications, including catheter or valve obstruction, shunt tubing fracture or disconnection, or proximal catheter migration out of the ventricle within 96 hours from presentation to the ED. Results: Seventy-six pairs of baseline and symptomatic ultrasonograms from 58 patients (mean [SD] age, 6.6 [4.7] years; 36 of 58 boys [62%]) were included. Twenty patients (35%) had 2 or more prior shunt revisions, and 29 (50%) had communicating hydrocephalus. The primary outcome of intraoperatively confirmed shunt failure was observed in 14 of 76 ED patient presentations (18%). The mean (SD) change in ONSD among patients with shunt failure was 0.89 (0.66) mm vs 0.16 (0.40) mm among patients without shunt failure (mean difference, 0.73 mm [95% CI, 0.47-0.99 mm]; P < .001). The odds of full shunt failure were 1.4 times higher (95% CI, 1.21-1.78; P < .001) for every 0.1-mm increase in ONSD. The area under the receiver operating characteristic curve was 0.86, with an optimal cutoff of 0.4 mm or more, yielding a sensitivity of 0.93, specificity of 0.73, positive predictive value of 0.43, and negative predictive value of 0.98, for a disease prevalence of 15%, with a positive likelihood ratio of 3.39 and negative likelihood ratio of 0.10. Conclusions and Relevance: In this single-center, prospective cohort study of symptomatic children with CSF shunts, a change in ONSD measured by ocular POCUS was associated with shunt failure. A change in ONSD from prior asymptomatic baseline to symptomatic presentation of less than 0.4 mm identified a population at low risk of true shunt failure. Further research is warranted to validate these findings, the presented change in ONSD threshold, and to risk stratify low-risk patients for cross-sectional neuroimaging.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.004 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.001 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".