Transverse Sinus Stenting for Pseudotumor Cerebri: A Cost Comparison with CSF Shunting

Total Revisions per Patient

To explore the potential cost implications of subsequent procedures, especially shunt revisions, a series of scenarios were developed on the basis of average costs from the 2 datasets supported by evidence from previous studies.9,10 These provided cross-validated estimates of the average cost of initial stenting or shunting, as well as of subsequent procedures, infection risk, and associated average infection cost. These scenarios are consistent with studies of adult patients with PTC shunts, as referenced in previous sections, which have shown infection and revision rates and the total number of shunt revisions per patient to be similar to those of our pediatric study group.

These findings then support a series of scenarios based on the total number of additional procedures per patient as presented in Fig 3. The maximum number of subsequent stentings in the 12-year group was 3, and additional stenting beyond 5 have not been reported, so 5 is considered the maximum upper limit. In this context, the first scenario illustrates the relative comparison of 5 subsequent stentings and 5 subsequent shunt revisions, with the slightly higher total cost of shunting due to the additional cost of managing infections.

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Additional scenarios were prepared to investigate a reduced infection rate for CSF shunting with use of antibiotic-impregnated shunts, which included infection rates below those reported in previous adult study groups.17

In the scenarios of 8 and then 10 revisions, shown only for shunts, the trend is further established. While 10 revisions are presented as an extreme scenario, there have been reports of adult patients with PTC needing even more, which extends the increasing cost trend for patients with higher revision shunts.14,18

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Previous modeling suggests that the cost of shunting in pediatric hydrocephalus is more sensitive to the revision rate, particularly in the first year after shunting, than to the decreased infection rate or length of hospital stay.19 Also long-term investigations of shunted children have confirmed that 81% need at least 1 revision and often several, requiring repeated procedures and hospitalizations.13

The shunt infection column bars in Fig 3 report the shunt infection rate of the study group (16.8%), which is shown against 2 reduced-infection-rate sensitivity scenarios of 10% and 5%. These scenarios indicate that even with an infection rate of only 5%, a patient receiving 10 shunt revisions is estimated to cost $196,771, almost a 4-fold increase in the highest cost of inserting 5 additional stents. Despite reported examples of reduced shunt infection rates, rates of 10% still occur even with antibiotic-impregnated shunts.20 As described previously, adult patient groups with PTC shunts have been reported as having a similar 9% infection rate. Here, the estimated cost of $239,136 is close to 5-fold the highest cost for a stented patient. In all scenarios with >5 subsequent procedures, an increasing upward cost trend resulted for shunts, in line with the number of procedures, shown as the dotted triangle in Fig 3.

In summary, the average cost per 100 patients, the total cost per patient, and the skewed upside risk of additional costs through ongoing shunt revisions and infections show stenting costing less than shunting, while nonetheless providing patients with PTC with effective long-term treatment.

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