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Nagy A, Bognar L, Pataki I, Barta Z, Novak L. Ventriculosubgaleal shunt in the treatment of posthemorrhagic and postinfectious hydrocephalus of premature infants. Childs Nerv Syst 2013. [PMID: 23207973 DOI: 10.1007/s00381-012-1968-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of the study was to compare the characteristics of ventriculosubgaleal shunts during the clinical course of posthemorrhagic and postinfectious hydrocephalus in the neonatal period. PATIENTS AND METHODS The study comprised 102 premature babies in whom subgaleal shunt was consecutively inserted between 2006 and 2011. Seventy-two patients had posthemorrhagic hydrocephalus (mean gestational age 27.3 ± 2.1 weeks, mean birth weight 1,036.9 ± 327.7 g, mean age at insertion 51.4 ± 56.2 days) and 30 patients were operated postinfectiously (27.5 ± 2.2 weeks, 1,064.7 g ± 310.7 g, 115.9 ± 47.8 days). RESULTS The mean survival of subgaleal shunts was 87.9 days for the posthemorrhagic group and 75.6 days for the postinfectious group. Only six infants (8.3 %) did not need ventriculoperitoneal shunts later, all posthemorrhagic. There were meaningful differences between two groups with regard to ventriculosubgaleal shunt-related infections (8.3 % in posthemorrhagic versus 20.0 % in postinfectious) and shunt revision rate (6.9 % in posthemorrhagic versus 13.3 % in postinfectious), but these were not statistically significant. The need of ventriculoscopic procedures was notably more frequent in postinfectious group (1.4 versus 23.3 %). CONCLUSION In premature infants with ventriculomegaly, the subgaleal shunt is an effective temporary diversion tool. The complications were less with posthemorrhagic than with postinfectious hydrocephalus. With previous severe infections of prematures, the risk for complications regarding infection and obstruction will be 2.75 and 2.06 (odds ratios) times higher and more frequent need of ventriculoscopic procedures should be considered (odds ratio 21.6).
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Affiliation(s)
- Andrea Nagy
- Institute of Pediatrics, University of Debrecen Medical and Health Sciences Centre, Debrecen, Hungary
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Chesler DA, Pendleton C, Ahn ES, Quinones-Hinojosa A. Harvey Cushing's early management of hydrocephalus: an historical picture of the conundrum of hydrocephalus until modern shunts after WWII. Clin Neurol Neurosurg 2012; 115:699-701. [PMID: 22944467 DOI: 10.1016/j.clineuro.2012.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 07/15/2012] [Accepted: 08/04/2012] [Indexed: 11/16/2022]
Abstract
PURPOSE Throughout his early career, Cushing proposed a variety of methods for temporary and permanent drainage and diversion of CSF in his patients, and acknowledged that certain techniques were more suited to particular subsets of hydrocephalus. METHODS Following IRB approval, and through the courtesy of the Alan Mason Chesney Archives, the surgical records of the Johns Hopkins Hospital, from 1896 to 1912, were reviewed. Patients operated upon by Harvey Cushing were selected for further analysis. Within this cohort, we recovered all available records for a single patient with hydrocephalus and spina bifida, who was treated with a ventriculosubgaleal shunt prior to repair of the spina bifida. RESULTS A 3 month-old infant presented with hydrocephalus associated with spina bifida. Cushing performed serial lumbar and ventricular punctures. Following this, Cushing took the patient to the operating room for placement of a ventriculosubgaleal shunt. The patient subsequently underwent excision of the myelomeningocele sac, with post-operative mortality due to unspecified causes. CONCLUSIONS Cushing's publications document a preference for translumbar-peritoneal drainage in patients with congenital hydrocephalus, particularly those with spina bifida. Although the placement of ventriculosubgaleal shunts has become an accepted practice for contemporary neurosurgeons, this case illustrates the challenges that early neurosurgeons faced in developing operative approaches for the treatment of congenital hydrocephalus.
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Affiliation(s)
- David A Chesler
- The Johns Hopkins University School of Medicine, Department of Neurosurgery and Oncology, Baltimore, MD, United States
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Riva-Cambrin J, Shannon CN, Holubkov R, Whitehead WE, Kulkarni AV, Drake J, Simon TD, Browd SR, Kestle JRW, Wellons JC. Center effect and other factors influencing temporization and shunting of cerebrospinal fluid in preterm infants with intraventricular hemorrhage. J Neurosurg Pediatr 2012; 9:473-81. [PMID: 22546024 PMCID: PMC3361965 DOI: 10.3171/2012.1.peds11292] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT There is little consensus regarding the indications for surgical CSF diversion (either with implanted temporizing devices [reservoir or subgaleal shunt] or shunt alone) in preterm infants with posthemorrhagic hydrocephalus. The authors determined clinical and neuroimaging factors associated with the use of surgical CSF diversion among neonates with intraventricular hemorrhage (IVH), and describe variations in practice patterns across 4 large pediatric centers. METHODS The use of implanted temporizing devices and conversion to permanent shunts was examined in a consecutive sample of 110 neonates surgically treated for IVH related to prematurity from the 4 clinical centers of the Hydrocephalus Clinical Research Network (HCRN). Clinical, neuroimaging, and so-called processes of care factors were analyzed. RESULTS Seventy-three (66%) of the patients underwent temporization procedures, including 50 ventricular reservoir and 23 subgaleal shunt placements. Center (p < 0.001), increasing ventricular size (p = 0.04), and bradycardia (p = 0.07) were associated with the use of an implanted temporizing device, whereas apnea, occipitofrontal circumference (OFC), and fontanel assessments were not. Implanted temporizing devices were converted to permanent shunts in 65 (89%) of the 73 neonates. Only a full fontanel (p < 0.001) and increased ventricular size (p = 0.002) were associated with conversion of the temporizing devices to permanent shunts, whereas center, OFCs, and clot characteristics were not. CONCLUSIONS Considerable center variability exists in neurosurgical approaches to temporization of IVH in prematurity within the HCRN; however, variation between centers is not seen with permanent shunting. Increasing ventricular size-rather than classic clinical findings such as increasing OFCs-represents the threshold for either temporization or shunting of CSF.
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Affiliation(s)
- Jay Riva-Cambrin
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, Salt Lake City, UT, USA.
| | - Chevis N. Shannon
- Section of Pediatric Neurosurgery, Division of Neurosurgery, Children’s Hospital of Alabama, University of Alabama Birmingham, Alabama
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - William E. Whitehead
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | | | - James Drake
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Canada
| | - Tamara D. Simon
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, Washington
| | - Samuel R. Browd
- Department of Neurosurgery, University of Washington/Seattle Children’s Hospital, Seattle, Washington
| | - John R. W. Kestle
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah
| | - John C. Wellons
- Section of Pediatric Neurosurgery, Division of Neurosurgery, Children’s Hospital of Alabama, University of Alabama Birmingham, Alabama
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Kestle JRW. Editorial: intraventricular hemorrhage and posthemorrhagic hydrocephalus. J Neurosurg Pediatr 2012; 9:239-40; discussion 240-1. [PMID: 22380951 DOI: 10.3171/2011.11.peds11412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Simon TD, Whitlock KB, Riva-Cambrin J, Kestle JRW, Rosenfeld M, Dean JM, Holubkov R, Langley M, Mayer-Hamblett N. Association of intraventricular hemorrhage secondary to prematurity with cerebrospinal fluid shunt surgery in the first year following initial shunt placement. J Neurosurg Pediatr 2012; 9:54-63. [PMID: 22208322 PMCID: PMC3254255 DOI: 10.3171/2011.10.peds11307] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The neurosurgical literature has conflicting findings regarding the association between indications for CSF shunt placement and subsequent shunt surgery. The object of this study was to identify baseline factors at the time of initial CSF shunt placement that are independently associated with subsequent surgery. METHODS This was a retrospective cohort study of children ages 0-18 years who underwent initial CSF shunt placement between January 1, 1997, and October 12, 2006, at a tertiary care children's hospital. The outcome of interest was CSF shunt surgery (either for revision or infection) within 12 months after initial placement. Associations between subsequent CSF shunt surgery and indication for the initial shunt, adjusting for patient age and surgeon factors at the time of initial placement, were estimated using multivariate logistic regression. Medical and surgical decisions, which varied according to surgeon, were examined separately in a univariate analysis. RESULTS Of the 554 children in the study cohort, 233 (42%) underwent subsequent CSF shunt surgery, either for revision (167 patients [30%]) or infection (66 patients [12%]). In multivariate logistic regression modeling, significant risk factors for subsequent CSF shunt surgery included (compared with aqueductal stenosis) intraventricular hemorrhage (IVH) secondary to prematurity (adjusted odds ratio [AOR] 2.2, 95% CI 1.1-4.5) and other unusual indications (AOR 3.7, 95% CI 1.0-13.6). The patient's age at initial CSF shunt placement was not significantly associated with increased odds of subsequent surgery after adjusting for other associated factors. CONCLUSIONS The occurrence of IVH is associated with increased odds of subsequent CSF shunt surgery within 12 months after shunt placement. Families of and care providers for children with IVH should be attuned to their increased risk of shunt failure.
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Affiliation(s)
- Tamara D. Simon
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital,Seattle Children’s Hospital Research Institute, Seattle, Washington
| | | | - Jay Riva-Cambrin
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah/PCMC
| | - John R. W. Kestle
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah/PCMC
| | - Margaret Rosenfeld
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital,Seattle Children’s Hospital Research Institute, Seattle, Washington
| | - J. Michael Dean
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Richard Holubkov
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Marcie Langley
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah/PCMC
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital,Seattle Children’s Hospital Research Institute, Seattle, Washington
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Djientcheu VDP, Nguefack S, Mouafo TO, Mbarnjuk AS, Yamgoue TY, Bello F, Kagmeni G, Mbonda E, Rilliet B. Hydrocephalus in toddlers: the place of shunts in sub-Sahara African countries. Childs Nerv Syst 2011; 27:2097-100. [PMID: 21822959 DOI: 10.1007/s00381-011-1548-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 07/29/2011] [Indexed: 12/01/2022]
Abstract
PURPOSE This study describes the epidemiological patterns of hydrocephalus in toddlers in our setting in order to determine the proportion of those who could benefit from endoscopic third ventriculostomy (ETV). METHODS This prospective and descriptive study included all toddlers operated on for hydrocephalus from 1 March 2008 to 31 March 2010 at the Yaounde Central Hospital. RESULTS Forty-six toddlers were included representing 72% of all hydrocephalus cases managed at the Neurosurgery Unit during the study period. The mean age was 6.9 ± 1.6 months. The delay before treatment varied from 5 days to 15.8 months (mean = 3.7 ± 0.5 months). The commonest clinical presentation was macrocrania (78.3%). Of the toddlers, 58.7% presented with a probable blindness (loss of ocular pursuit); dilated and non-reactive pupils were found in nine patients (19.6%). The diagnosis was based on transfontanellar echography (TFE), CT scan or combined TFE and CT scan. Identified aetiologies were aqueduct stenosis (28.7%), haemorrhage (18%), Dandy-Walker's syndrome (14.3%), meningitis (10.8%), myelomeningocele (10.8%), agenesis of Monro's foramen (3.6%), brain abscess (3.2%) and posterior fossa tumour (3.6%). No specific cause was found in 7% of cases. The treatment was ventriculoperitoneal shunting in 42 cases (91.3%) and ETV in two cases (4.3%). Infections (11.1%) and shunts' obstruction (5.4%) were the main complications. CONCLUSION Cases of hydrocephalus in toddlers are frequent in our setting. Regardless of the patient's age, the most prevailing aetiologies (infections, haemorrhage, myelomeningocele) and technological conditions (neuroendoscope) are less favourable for ETV. The use of ETV in the treatment of hydrocephalus in sub-Saharan Africa is still marginal and needs to be encouraged in selected cases. The prevention of non-tumoral hydrocephalus is of critical importance.
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Initial experience with combined endoscopic third ventriculostomy and choroid plexus cauterization for post-hemorrhagic hydrocephalus of prematurity: the importance of prepontine cistern status and the predictive value of FIESTA MRI imaging. Childs Nerv Syst 2011; 27:1063-71. [PMID: 21556955 DOI: 10.1007/s00381-011-1475-0] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2010] [Accepted: 04/28/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Post-hemorrhagic hydrocephalus of prematurity (PHHP) is among the most common causes of infant hydrocephalus in developed nations. This population has a high incidence of shunt failure, infection, and slit ventricle syndrome. Although effective for other etiologies of infant hydrocephalus, the efficacy of combined endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC) in PHHP has not been investigated. This pilot study reports the initial experience. METHODS Ten patients (four grade III and six grade IV intraventricular hemorrhage) requiring definitive treatment for PHHP underwent ETV/CPC within 6 months of birth. Seven had a prior ventriculo-subgaleal shunt. Mean age at birth was -12.8 weeks, or 25.2 weeks gestation (24-28 weeks), and at surgery was -1.6 weeks (-11 to +11 weeks). Mean weight at surgery was 3.3 (1.0-5.5 kg). Each patient had preoperative magnetic resonance imaging (MRI) with fast imaging employing steady-state acquisition (FIESTA). RESULTS Four of ten (40%) required no further operations related to hydrocephalus (mean follow-up, 29.7 months). Six required another procedure (five ultimately shunted). Prepontine cistern status correlated with outcome (p = 0.033). Procedures in all infants with unobstructed cisterns were successful but failed in six of seven with cisternal obstruction, with the one success having an alternative lamina terminalis endoscopic third ventriculostomy. Preoperative MRI FIESTA images correlated well with intraoperative assessment of the cistern. CONCLUSIONS Results from this small homogenous cohort suggest cistern status is an important determinant of outcome. FIESTA imaging correlated with endoscopic observation. Preliminary analysis suggests ETV/CPC as an effective treatment for PHHP, but only when the cistern is unscarred. This information should guide patient selection for future study protocols.
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Fulkerson DH, Vachhrajani S, Bohnstedt BN, Patel NB, Patel AJ, Fox BD, Jea A, Boaz JC. Analysis of the risk of shunt failure or infection related to cerebrospinal fluid cell count, protein level, and glucose levels in low-birth-weight premature infants with posthemorrhagic hydrocephalus. J Neurosurg Pediatr 2011; 7:147-51. [PMID: 21284459 DOI: 10.3171/2010.11.peds10244] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Premature, low-birth-weight infants with posthemorrhagic hydrocephalus have a high risk of shunt obstruction and infection. Established risk factors for shunt failure include grade of the hemorrhage and age at shunt insertion. There is anecdotal evidence that the amount of red blood cells or protein levels in the CSF may affect shunt performance. However, this has not been analyzed specifically for this cohort of high-risk patients. Therefore, the authors performed this study to examine whether any statistical relationship exists between the CSF constituents and the rate of shunt malfunction or infection in this population. METHODS A retrospective cohort study was performed on premature infants born at Riley Hospital for Children from 2000 to 2009. Inclusion criteria were a CSF sample analyzed within 2 weeks prior to shunt insertion, low birth weight (< 1500 grams), prematurity (birth prior to 37 weeks estimated gestational age), and shunt insertion for posthemorrhagic hydrocephalus. Data points included the gestational age at birth and shunt insertion, weight at birth and shunt insertion, history of CNS infection prior to shunt insertion, shunt failure, shunt infection, and the levels of red blood cells, white blood cells, protein, and glucose in the CSF. Statistical analysis was performed to determine any association between shunt outcome and the CSF parameters. RESULTS Fifty-eight patients met the study entry criteria. Ten patients (17.2%) had primary shunt failure within 3 months of insertion. Nine patients (15.5%) had shunt infection within 3 months. A previous CNS infection prior to shunt insertion was a statistical risk factor for shunt failure (p = 0.0290) but not for shunt infection. There was no statistical relationship between shunt malfunction or infection and the CSF levels of red blood cells, white blood cells, protein, or glucose before shunt insertion. CONCLUSIONS Low-birth-weight premature infants with posthemorrhagic hydrocephalus have a high rate of shunt failure and infection. The authors did not find any association of shunt failure or infection with CSF cell count, protein level, or glucose level. Therefore, it may not be useful to base the timing of shunt insertion on CSF parameters.
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Affiliation(s)
- Daniel H Fulkerson
- Department of Neurosurgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana 46202, USA.
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Petraglia AL, Moravan MJ, Dimopoulos VG, Silberstein HJ. Ventriculosubgaleal shunting--a strategy to reduce the incidence of shunt revisions and slit ventricles: an institutional experience and review of the literature. Pediatr Neurosurg 2011; 47:99-107. [PMID: 21921577 DOI: 10.1159/000330539] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 07/03/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Slit ventricles and multiple episodes of shunt failure are problematic in many infants and preterm neonates shunted for hydrocephalus. We utilized ventriculosubgaleal (VSG) shunting as the initial neurosurgical intervention in neonates with hydrocephalus associated with intraventricular hemorrhage and infants with myelomeningocele. METHODS We conducted a chart review of 21 children initially treated with a VSG shunt between November 2002 and July 2009. Patient records and imaging studies were reviewed. Demographics, case data and clinical outcome were collected. RESULTS Five patients (27.8%) required a revision after conversion to a ventriculoperitoneal (VP) shunt. There were 9 cases of radiographic slit ventricles (45%). Average follow-up was 59.5 months (range 12-97 months). Average time interval to shunt conversion was 81.5 days. Two patients have not required conversion to a VP shunt (one with an 8-year follow-up). To date, none of these patients has required a subtemporal window or cranial vault expansion. CONCLUSION Based on our results, initial management of selected hydrocephalic infants with a VSG shunt may prove to be advantageous in the long run for these children as the number of shunt revisions and the incidence of slit ventricles are significantly less than those reported in the literature.
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Affiliation(s)
- Anthony L Petraglia
- Department of Neurosurgery, University of Rochester Medical Center and Golisano Children's Hospital, Rochester, NY 14642, USA.
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Hidrocefalia poshemorrágica asociada a la prematuridad: evidencia disponible diagnóstica y terapéutica. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70033-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Limbrick DD, Mathur A, Johnston JM, Munro R, Sagar J, Inder T, Park TS, Leonard JL, Smyth MD. Neurosurgical treatment of progressive posthemorrhagic ventricular dilation in preterm infants: a 10-year single-institution study. J Neurosurg Pediatr 2010; 6:224-30. [PMID: 20809705 DOI: 10.3171/2010.5.peds1010] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intraventricular hemorrhage (IVH) and progressive posthemorrhagic ventricular dilation (PPHVD) may result in significant neurological morbidity in preterm infants. At present, there is no consensus regarding the optimal timing or type of neurosurgical procedure to best treat PPHVD. Conflicting data exist regarding the relative risks and benefits of two commonly used temporizing neurosurgical procedures (TNPs), ventricular access devices ([VADs] or ventricular reservoirs) versus ventriculosubgaleal (VSG) shunts. This study was designed to address this issue. METHODS This is a single-center, 10-year retrospective review of all preterm infants admitted to the St. Louis Children's Hospital neonatal intensive care unit (NICU) with Papile Grade III-IV IVH. The development of PPHVD and the requirement for and type of TNP were recorded. Rates of TNP complication, ventriculoperitoneal (VP) shunt implantation, shunt infection, and mortality rates were used to compare the efficacy and limitations of each TNP type. RESULTS Over this 10-year interval, 325 preterm infants with Grade III-IV IVH were identified, with trends showing an increasing number of affected infants annually, and an increasing number of TNPs were required annually. Ninety-five (29.2%) of the 325 infants underwent a TNP for PPHVD (65 VADs, 30 VSG shunts). The rate of permanent VP shunt implantation for all TNPs was 72.6% (69 of 95 infants). Forty-nine (75.4%) of the 65 infants treated with VADs and 20 (66.7%) of the 30 treated with VSG shunts required VP shunts (p = 0.38). There was no statistical difference between VAD or VSG shunt with regard to TNP-related infection (p = 0.57), need for TNP revision (p = 0.16), subsequent shunt infection (p = 0.77), shunt revision rate (p = 0.58), or mortality rate (p = 0.24). CONCLUSIONS Rates of IVH and PPHVD observed at the authors' center have increased over time. In contrast to recent literature, the results from the current study did not demonstrate a difference in complication rate or requirement for permanent VP shunt placement between VADs and VSG shunts. Definitive conclusions will require a larger, prospective trial.
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Affiliation(s)
- David D Limbrick
- Department of Neurological Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri 63110-1077, USA.
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