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Validating a Clinical Prediction Rule for Ventricular Shunt Malfunction

Boyle, Tehnaz P., MD, PhD*; Kimia, Amir A., MD; Nigrovic, Lise E., MD, MPH

doi: 10.1097/PEC.0000000000001032
Original Articles

Objective This study aims to validate a published ventricular shunt clinical prediction rule for the identification of children at low risk for ventricular shunt malfunction based on the absence of 3 high-risk clinical predictors (irritability, nausea or vomiting, and headache).

Methods We identified children aged 21 years and younger with a ventricular shunt who presented between 2010 and 2013 to a single pediatric emergency department (ED) for evaluation of potential shunt malfunction. We defined a ventricular shunt malfunction as obstruction to cerebrospinal fluid flow requiring operative neurosurgical intervention within 72 hours of initial ED evaluation. We applied this ventricular shunt clinical prediction rule to the study population and report the test characteristics.

Results We identified 755 ED visits for 294 children with potential ventricular shunt malfunction. Of these encounters, 146 (19%; 95% confidence interval [CI], 17%–22%) had a ventricular shunt malfunction. The ventricular shunt clinical prediction rule had a sensitivity of 99% (95% CI, 94%–100%), specificity of 7% (95% CI, 5%–9%), and negative predictive value of 95% (95% CI, 82%–99%). Two children with a ventricular shunt malfunction were misclassified as low risk by this clinical prediction rule.

Conclusions Ventricular shunt malfunctions were common. Although children classified as low risk by the ventricular shunt clinical prediction rule were less likely to have a shunt malfunction, routine neuroimaging may still be required because exclusion of ventricular shunt malfunction may be difficult on clinical grounds alone.

From the *Division of Pediatric Emergency Medicine, Boston Medical Center; and

Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.

Disclosure: The authors declare no conflicts of interest.

Reprints: Tehnaz P. Boyle, MD, PhD, Division of Pediatric Emergency Medicine, Boston Medical Center, Boston University School of Medicine, 88 E Newton, Vose 5, Boston, MA 02118 (e-mail:

This study was supported by a Boston Children's Hospital House Officer Development Award.

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