Expanded role of the cerebrospinal fluid reservoir in neurooncology: Indications, causes of revision, and complications

Advances in chemotherapy have increased the indications for insertion of cerebrospinal fluid (CSF) reservoirs in the treatment of both primary and secondary central nervous system neoplasia. There have been no recent evaluations of the current indications and complications of this procedure in a general neurooncology practice. We undertook a retrospective review of our total experience of 60 patients who were implanted with CSF reservoirs between November 1977 and October 1983. The mean age of those implanted was 38 years (range, 22 months to 79 years). The reasons for insertion were: drug instillation, 35 cases (58.3%); drug level monitoring, 15 cases (25.0%); intermittent tumor cyst drainage, 6 cases (15.0%); and syrinx drainage, 1 case (1.6%). Drug level monitoring was most often done in conjunction with specific experimental chemotherapy protocols. There were no complications after primary insertion, but 9 of 60 reservoirs (15%) required revision for technical failure. Revision was much more likely to occur in the presence of an intracranial mass lesion (7 of 34, or 20.5%). The revision rate in cases of meningeal carcinomatosis was only 7.6% (2 of 26). Patients requiring revision included 5 with glioblastoma, 2 with metastatic tumors, and 2 with meningeal carcinomatosis. Four of the 9 patients requiring revisions developed complications (44%). There were three infections with positive CSF cultures and one subdural hematoma. Infected patients included those with multiple craniotomies, prior cranial irradiation, or some form of chemotherapy. We conclude that primary insertion of a CSF reservoir in a patient with neoplastic involvement of the central nervous system is extremely safe, that technical failure tends to occur in the presence of mass lesions, and that the complication rate of repeated insertion is quite high.