Complications of ventriculosubgaleal shunts in infants and children

Function and Biomarkers of the Blood-Brain Barrier in a Neonatal Germinal Matrix Haemorrhage Model

Germinal matrix haemorrhage (GMH), caused by rupturing blood vessels in the germinal matrix, is a prevalent driver of preterm brain injuries and death. Our group recently developed a model simulating GMH using intrastriatal injections of collagenase in 5-day-old rats, which corresponds to the brain development of human preterm infants. This study aimed to define changes to the blood-brain barrier (BBB) and to evaluate BBB proteins as biomarkers in this GMH model. Regional BBB functions were investigated using blood to brain ¹⁴C-sucrose uptake as well as using biotinylated BBB tracers. Blood plasma and cerebrospinal fluids were collected at various times after GMH and analysed with ELISA for OCLN and CLDN5. The immunoreactivity of BBB proteins was assessed in brain sections. Tracer experiments showed that GMH produced a defined region surrounding the hematoma where many vessels lost their integrity. This region expanded for at least 6 h following GMH, thereafter resolution of both hematoma and re-establishment of BBB function occurred. The sucrose experiment indicated that regions somewhat more distant to the hematoma also exhibited BBB dysfunction; however, BBB function was normalised within 5 days of GMH. This shows that GMH leads to a temporal dysfunction in the BBB that may be important in pathological processes as well as in connection to therapeutic interventions. We detected an increase of tight-junction proteins in both CSF and plasma after GMH making them potential biomarkers for GMH.

Ventriculo-subgaleal shunts-broadening the horizons: an institutional experience

OBJECTIVE

Ventriculo-subgaleal shunt is an established treatment of hydrocephalus following germinal matrix haemorrhage in low birth weight neonates. It is also used in treatment of post-infective hydrocephalus in children. We intend to emphasise the impact of its extended use in multiple clinical conditions to reduce the number of permanent shunt implantation in infants.

METHOD

Retrospective review of clinical cases in a single institution from medical records.

RESULTS

VSG shunts with low-pressure valve system were useful in variety of hydrocephalus in infants (post-haemorrhagic, post-infective, post-myelomeningocele, post-shunt block, post-traumatic, hydrocephalus associated with brain tumours). A significant number of infants especially those with post-haemorrhagic and post-myelomeningocele hydrocephalus could be made free of permanent shunt placement.

CONCLUSIONS

Ventriculo-subgaleal shunt is an effective, less risky temporary solution of hydrocephalus in infants and can be used in a variety of hydrocephalus in children and helps in avoiding shunt dependency in some of them.

Ventriculosubgaleal shunt and neuroendoscopic lavage: refining the treatment algorithm of neonatal post-hemorrhagic hydrocephalus

BACKGROUND

The optimal management of neonatal post-hemorrhagic hydrocephalus (PHH) is still debated, though several treatment options have been proposed. In the last years, ventriculosubgaleal shunt (VSgS) and neuroendosdcopic lavage (NEL) have been proposed to overcome the drawbacks of more traditional options, such as external ventricular drainage and ventricular access device.

METHODS

We retrospectively reviewed neonates affected by PHH treated at our institution since September 2012 to September 2020. Until 2017 patients received VSgS as initial treatment. After the introduction of NEL, this treatment option was offered to patients with large intraventricular clots. After NEL, VSgS was always placed. Primary VSgS was reserved to patients without significant intraventricular clots and critically ill patients that could not be transferred to the operating room and undergo a longer surgery.

RESULTS

We collected 63 babies (38 males and 25 females) with mean gestational age of 27.8 ± 3.8SD weeks (range 23-38.5 weeks) and mean birthweight of 1199.7 ± 690.6 SD grams (range 500-3320 g). In 6 patients, hemorrhage occurred in the third trimester of gestation, while in the remaining cases hemorrhage complicated prematurity. This group included 37 inborn and 26 outborn babies. Intraventricular hemorrhage was classified as low grade (I-II according to modified Papile grading scale) in 7 cases, while in the remaining cases the grade of hemorrhage was III to IV. Mean age at first neurosurgical procedure was 32.2 ± 3.6SD weeks (range 25.4-40 weeks). Death due to prematurity occurred in 5 patients. First-line treatment was VSgS in 49 patients and NEL in the remaining 14 cases. Mean longevity of VSgS was 30.3 days (range 10-97 days) in patients finally requiring an additional treatment of hydrocephalus. Thirty-two patients required one to three redo VSgS. Interval from initial treatment to permanent shunt ranged from 14 to 312 days (mean 70.9 days). CSF infection was observed in 5 patients (7.9%). Shunt dependency was observed in 51 out of 58 surviving patients, while 7 cases remained shunt-free at the last follow-up. Multiloculated hydrocephalus was observed in 14 cases. Among these, only one patient initially received NEL and was complicated by isolated trapped temporal horn.

CONCLUSIONS

VSgS and NEL are two effective treatment options in the management of PHH. Both procedures should be part of the neurosurgical armamentarium to deal with PHH, since they offer specific advantages in selected patients. A treatment algorithm combining these two options may reduce the infectious risk and the risk of multiloculated hydrocephalus.

Functional outcomes at 2 years of age following treatment for posthemorrhagic hydrocephalus of prematurity: what do we know at the time of consult?

OBJECTIVE

Posthemorrhagic hydrocephalus of prematurity remains a significant problem in preterm infants. In the literature, there is a scarcity of data on the early disease process, when neurosurgeons are typically consulted for recommendations on treatment. Here, the authors sought to evaluate functional outcomes in premature infants at 2 years of age following treatment for posthemorrhagic hydrocephalus. Their goal was to determine the relationship between factors identifiable at the time of the initial neurosurgical consult and outcomes of patients when they are 2 years of age.

METHODS

The authors performed a retrospective chart review of premature infants treated for intraventricular hemorrhage (IVH) of prematurity (grade III and IV) between 2003 and 2014. Information from three time points (birth, first neurosurgical consult, and 2 years of age) was collected on each patient. Logistic regression analysis was performed to determine the association between variables known at the time of the first neurosurgical consult and each of the outcome variables.

RESULTS

One hundred thirty patients were selected for analysis. At 2 years of age, 16% of the patients had died, 88% had cerebral palsy/developmental delay (CP), 48% were nonverbal, 55% were nonambulatory, 33% had epilepsy, and 41% had visual impairment. In the logistic regression analysis, IVH grade was an independent predictor of CP (p = 0.004), which had an estimated probability of occurrence of 74% in grade III and 96% in grade IV. Sepsis at or before the time of consult was an independent predictor of visual impairment (p = 0.024), which had an estimated probability of 58%. IVH grade was an independent predictor of epilepsy (p = 0.026), which had an estimated probability of 18% in grade III and 43% in grade IV. The IVH grade was also an independent predictor of verbal function (p = 0.007), which had an estimated probability of 68% in grade III versus 41% in grade IV. A higher weeks gestational age (WGA) at birth was an independent predictor of the ability to ambulate (p = 0.0014), which had an estimated probability of 15% at 22 WGA and up to 98% at 36 WGA. The need for oscillating ventilation at consult was an independent predictor of death before 2 years of age (p = 0.001), which had an estimated probability of 42% in patients needing oscillating ventilation versus 13% in those who did not.

CONCLUSIONS

IVH grade was consistently an independent predictor of functional outcomes at 2 years. Gestational age at birth, sepsis, and the need for oscillating ventilation may also predict worse functional outcomes.

Risk factors associated with conversion of an Ommaya reservoir to a permanent cerebrospinal fluid shunt in preterm posthemorrhagic hydrocephalus

OBJECTIVE

A considerable percentage of preterm infants with posthemorrhagic hydrocephalus initially managed with an Ommaya reservoir require a permanent CSF shunt. The objective of the study was to analyze possible risk factors associated with the need for converting an Ommaya reservoir to a permanent shunt.

METHODS

The authors retrospectively reviewed the clinical records of premature infants weighing 1500 g or less with posthemorrhagic hydrocephalus (Papile grades III and IV) managed with an Ommaya reservoir at their institution between 2002 and 2017.

RESULTS

Forty-six patients received an Ommaya reservoir. Five patients (10.9%) were excluded due to intraventricular infection during management with an Ommaya reservoir. Average gestational age and weight for the remaining 41 patients was 27 ± 1.8 weeks and 987 ± 209 grams, respectively. Thirty patients required a permanent shunt and 11 patients did not require a permanent shunt. The conversion rate from an Ommaya reservoir to a permanent shunt was 76.1%. Symptomatic persistent ductus arteriosus (PDA) was more frequent in the nonpermanent shunt group than in the shunt group (88.9% vs 50%, p = 0.04). The need for extraction of more than 10 ml/kg per day of CSF through the Ommaya reservoir was lower in the nonpermanent shunt group than in the shunt group (9.1% vs 51.7%, p = 0.015). CSF lactate was lower in the nonpermanent group than in the shunt group (mean 2.48 mg/dl vs 3.19 mg/dl; p = 0.004). A cutoff value of ≥ 2.8 mg/dl CSF lactate predicted the need for a permanent shunt with sensitivity and specificity of 82.4% and 80%, respectively. There were no significant differences in gestational age, sex, weight, Papile grade, ventricular index, or other biochemical markers. After the multivariate analysis, only CSF lactate ≥ 2.8 mg/dl was associated with a higher conversion rate to a permanent shunt.

CONCLUSIONS

This study showed that a high level of CSF lactate, absence of symptomatic PDA, and a higher CSF extraction requirement were associated with a higher likelihood of implanting a permanent CSF shunt. The authors believe these findings should be considered in future studies.

Overdrainage-related ependymal bands: a postulated cause of proximal shunt obstruction

OBJECTIVEVentricular shunts have an unacceptably high failure rate, which approaches 50% of patients at 2 years. Most shunt failures are related to ventricular catheter obstruction. The literature suggests that obstructions are caused by in-growth of choroid plexus and/or reactive cellular aggregation. The authors report endoscopic evidence of overdrainage-related ventricular tissue protrusions ("ependymal bands") that cause partial or complete obstruction of the ventricular catheter.METHODSA retrospective review was completed on patients undergoing shunt revision surgery between 2008 and 2015, identifying all cases in which the senior author reported endoscopic evidence of ependymal tissue in-growth into ventricular catheters. Detailed clinical, radiological, and surgical findings are described.RESULTSFifty patients underwent 83 endoscopic shunt revision procedures that revealed in-growth of ventricular wall tissue into the catheter tip orifices (ependymal bands), producing partial, complete, or intermittent shunt obstructions. Endoscopic ventricular explorations revealed ependymal bands at various stages of development, which appear to form secondarily to siphoning. Ependymal bands are associated with small ventricles when the shunt is functional, but may dilate at the time of obstruction.CONCLUSIONSVentricular wall protrusions are a significant cause of proximal shunt obstruction, and they appear to be caused by siphoning of surrounding tissue into the ventricular catheter orifices.

Ventriculosubgaleal shunting-a comprehensive review and over two-decade surgical experience

INTRODUCTION

The subgaleal space is the fibroareolar layer found between the galea aponeurotica and the periosteum of the scalp. Due to its elastic and absorptive capabilities, the subgaleal space can be used as a shunt to drain excess cerebrospinal fluid from the ventricles. A subgaleal shunt consists of a shunt tube with one end in the lateral ventricles while the other end is inserted into the subgaleal space of the scalp. This will allow for the collection and absorption of excess cerebrospinal fluid. Indications for ventriculosubgaleal shunting (VSG) include acute head trauma, subdural hematoma, and malignancies.

DISCUSSION

VSG shunt is particularly advantageous for premature infants suffering from post-hemorrhagic hydrocephalus due to their inability to tolerate long-term management such as a ventriculoperitoneal shunt. Complications include infection and shunt blockage. In comparison with other short-term treatments of hydrocephalus, the VSG exhibits significant advantages in the drainage of excess cerebrospinal fluid. VSG shunt is associated with lower infection rates than other external ventricular drain due to the closed system of CSF drainage and lack of external tubes.

CONCLUSION

This review discusses the advantages and disadvantages of the VSG shunt, as well as our personal experience with the procedure.

Outcome of Ventriculosubgaleal Shunt in the Management of Infectious and Non-infectious Hydrocephalus in Pre-term Infants

Background:

Hydrocephalus in premature infants is an onerous disease. In such situations, choosing the best option for cerebrospinal fluid (CSF) diversion is difficult. Ventriculosubgaleal shunt is an effective method of temporary CSF diversion in such situations. In this retrospective study, we compare the outcome of ventriculosubgaleal shunt in premature infants with hydrocephalus of infectious and noninfectious etiology.

Materials and Methods:

All premature children with hydrocephalus secondary to various etiologies who underwent ventriculosubgaleal shunt were studied. The participants were grouped into two depending upon the etiology of hydrocephalus: Group 1 (infectious) and Group 2 (non-infectious). The primary outcome was a successful conversion to ventriculoperitoneal shunt (VPS) and the secondary outcome was mortality. Data were entered into statistical software SPSS version 16 and appropriate statistical analysis was performed to conclude any statistical significance between groups.

Results:

The study included 16 infants among whom 9 were in the infectious group and 7 in the non-infectious group. Primary end point of conversion to VPS was achieved in 55.5% of patients in group 1 and 85.7% in group 2. The secondary end point, i.e., mortality was observed in 44.4% of patients in group 1 and 14.2% in group 2. The average duration during which this was achieved was 40 days (range 20–60 days) in group 1 and 25 days (range 20–30 days) in group 2.

Conclusion:

Ventriculosubgaleal shunt is a safe and effective procedure in infants awaiting definitive VPS for hydrocephalus of infectious as well as noninfectious origin. There was no statistical difference in the rate of successful conversion to a permanent VPS from ventriculosubgaleal shunt in hydrocephalus of either etiologies. Complications and time for successful conversion were more in postmeningitic hydrocephalus.

Comparison of the use of ventricular access devices and ventriculosubgaleal shunts in posthaemorrhagic hydrocephalus: systematic review and meta-analysis

INTRODUCTION

Ventricular access devices (VAD) and ventriculosubgaleal shunts (VSGS) are currently both used as temporising devices to affect CSF drainage in neonatal posthaemorrhagic hydrocephalus (PHH), without clear evidence of superiority of either procedure. In this systematic review and meta-analysis, we compared the VSGS and VAD regarding complication rates, ventriculoperitoneal shunt conversion and infection rates, and mortality and long-term disability.

METHODS

The review was registered with the PROSPERO international prospective register of systematic reviews (registration number CRD42015019750) and was conducted in accordance with PRISMA guidelines.

RESULTS AND CONCLUSIONS

The literature search of five databases identified 338 publications, of which 5 met the inclusion criteria. All were retrospective cohort studies (evidence class 3b and 4). A significantly lower proportion of patients with a VSGS required CSF tapping compared to patients with a VAD (log OR -4.43, 95% CI -6.14 to -2.72). No other significant differences between the VAD and VSGS were identified in their rates of infection (log OR 0.03, 95% CI -0.77 to 0.84), obstruction (log OR 1.25, 95% CI -0.21 to 2.71), ventriculoperitoneal shunt dependence (log OR -0.06, 95% CI -0.93 to 0.82), subsequent shunt infection (log OR 0.23, 95% CI -0.61 to 1.06), mortality (log OR 0.37, 95% CI -0.95 to 1.70) or long-term disability (p = 0.9). In all studies, there was a lack of standardised criteria, variations between surgeons in heterogeneous cohorts of limited sample size and a lack of neurodevelopmental follow-up. This affirms the importance of an ongoing multicentre, prospective pilot study comparing these two temporising procedures to enable a more robust comparison.

Subdural to subgaleal shunts: alternative treatment in infants with nonaccidental traumatic brain injury?

OBJECT

The ideal treatment for subdural hematomas (SDHs) in infants remains debated. The aim of this study was to analyze the safety and efficiency of subduro-subgaleal drainage in SDH.

METHODS

The authors conducted a single-center open-label study between August 2011 and May 2012. Data were prospectively collected in a database and retrospectively analyzed.

RESULTS

Eighteen patients (male/female ratio 1.25) with a median age of 5 months were surgically treated. All had preoperative symptoms of intracranial hypertension or seizures. The SDH was bilateral in 16 cases, with a median width of 12 mm. Success of the procedure was noted in 14 of the 18 patients. There was no intraoperative complication or postoperative infection. Drainage failure was attributable to suboptimal positioning of the subdural drain in 2 cases and to migration in 1 case.

CONCLUSIONS

Subduro-subgaleal drainage is an efficient treatment that could be proposed as an alternative to external subdural drainage or subduroperitoneal drainage.

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 2: Management of posthemorrhagic hydrocephalus in premature infants

OBJECT

The objective of this systematic review and analysis was to answer the following question: What are the optimal treatment strategies for posthemorrhagic hydrocephalus (PHH) in premature infants?

METHODS

Both the US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to PHH. Two hundred thirteen abstracts were reviewed, after which 98 full-text publications that met inclusion criteria that had been determined a priori were selected and reviewed.

RESULTS

Following a review process and an evidentiary analysis, 68 full-text articles were accepted for the evidentiary table and 30 publications were rejected. The evidentiary table was assembled linking recommendations to strength of evidence (Classes I-III).

CONCLUSIONS

There are 7 recommendations for the management of PHH in infants. Three recommendations reached Level I strength, which represents the highest degree of clinical certainty. There were two Level II and two Level III recommendations for the management of PHH. Recommendation Concerning Surgical Temporizing Measures: I. Ventricular access devices (VADs), external ventricular drains (EVDs), ventriculosubgaleal (VSG) shunts, or lumbar punctures (LPs) are treatment options in the management of PHH. Clinical judgment is required.

STRENGTH OF RECOMMENDATION

Level II, moderate degree of clinical certainty. Recommendation Concerning Surgical Temporizing Measures: II. The evidence demonstrates that VSG shunts reduce the need for daily CSF aspiration compared with VADs.

STRENGTH OF RECOMMENDATION

Level II, moderate degree of clinical certainty. Recommendation Concerning Routine Use of Serial Lumbar Puncture: The routine use of serial lumbar puncture is not recommended to reduce the need for shunt placement or to avoid the progression of hydrocephalus in premature infants.

STRENGTH OF RECOMMENDATION

Level I, high clinical certainty. Recommendation Concerning Nonsurgical Temporizing Agents: I. Intraventricular thrombolytic agents including tissue plasminogen activator (tPA), urokinase, or streptokinase are not recommended as methods to reduce the need for shunt placement in premature infants with PHH.

STRENGTH OF RECOMMENDATION

Level I, high clinical certainty. Recommendation Concerning Nonsurgical Temporizing Agents. II. Acetazolamide and furosemide are not recommended as methods to reduce the need for shunt placement in premature infants with PHH.

STRENGTH OF RECOMMENDATION

Level I, high clinical certainty. Recommendation Concerning Timing of Shunt Placement: There is insufficient evidence to recommend a specific weight or CSF parameter to direct the timing of shunt placement in premature infants with PHH. Clinical judgment is required.

STRENGTH OF RECOMMENDATION

Level III, unclear clinical certainty. Recommendation Concerning Endoscopic Third Ventriculostomy: There is insufficient evidence to recommend the use of endoscopic third ventriculostomy (ETV) in premature infants with posthemorrhagic hydrocephalus.

STRENGTH OF RECOMMENDATION

Level III, unclear clinical certainty.

Ventricular reservoir versus ventriculosubgaleal shunt for posthemorrhagic hydrocephalus in preterm infants: infection risks and ventriculoperitoneal shunt rate

OBJECT

The most common neurosurgical condition observed in preterm infants is intraventricular hemorrhage (IVH), which often results in posthemorrhagic hydrocephalus (PHH). These conditions portend an unfavorable prognosis; therefore, the potential for poor neurodevelopmental outcomes necessitates a better understanding of the comparative effectiveness of 2 temporary devices commonly used before the permanent insertion of a ventriculoperitoneal (VP) shunt: the ventricular reservoir and the ventriculosubgaleal shunt (VSGS).

METHODS

The authors analyzed retrospectively collected information for 90 patients with IVH and PHH who were treated with insertion of a ventricular reservoir (n = 44) or VSGS (n = 46) at their institution over a 14-year period.

RESULTS

The mean gestational age and weight at device insertion were lower for VSGS patients (30.1 ± 1.9 weeks, 1.12 ± 0.31 kg) than for reservoir patients (31.8 ± 2.9 weeks, 1.33 ± 0.37 kg; p = 0.002 and p = 0.004, respectively). Ventricular reservoir insertion was predictive of more CSF taps prior to VP shunt placement compared with VSGS placement (10 ± 8.7 taps vs 1.6 ± 1.7 taps, p < 0.001). VSGS patients experienced a longer time interval prior to VP shunt placement than reservoir patients (80.8 ± 67.5 days vs 48.8 ± 26.4 days, p = 0.012), which corresponded to VSGS patients gaining more weight by the time of shunt placement than reservoir patients (3.31 ± 2.0 kg vs 2.42 ± 0.63 kg, p = 0.016). Reservoir patients demonstrated a trend toward more positive CSF cultures compared with VSGS patients (n = 9 [20.5%] vs n = 5 [10.9%], p = 0.21). There were no significant differences in the rates of overt device infection requiring removal (reservoir, 6.8%; VSGS, 6.5%), VP shunt insertion (reservoir, 77.3%; VSGS, 76.1%), or early VP shunt infection (reservoir, 11.4%; VSGS, 13.0%) between the 2 cohorts.

CONCLUSIONS

Although the rates of VP shunt requirement and device infection were similar between patients treated with the reservoir versus the VSGS, VSGS patients were significantly older and had achieved greater weights at the time of VP shunt insertion. The authors' results suggest that the VSGS requires less labor-intensive management by ventricular tapping; the VSGS patients also attained higher weights and more optimal surgical candidacy at the time of VP shunt insertion. The potential differences in long-term developmental and neurological outcomes between VSGS and reservoir placement warrant further study.

Recurrent cerebrospinal fluid shunt infection and the efficacy of reusing infected ventricular entry sites

OBJECT

The objective of this investigation was to review the clinical characteristics of recurrent CSF shunt infections in a large pediatric neurosurgical practice and to assess the safety and efficacy of reusing original ventricular entry sites for external ventricular drainage during treatment of infections and for subsequent reinsertion of shunts.

METHODS

Prospectively accrued clinical data on all patients treated at Children's Hospital Colorado for CSF shunt infections within a 10.5-year span were retrospectively investigated.

RESULTS

One hundred twenty-one consecutive cases of CSF shunt infection met inclusion criteria. Recurrent shunt infection attributable to the management of these infections occurred in 14 cases (11.6%). Three recurrent infections were with their original organisms, 7 were organisms different from the original organisms, and 4 were indeterminate.

CONCLUSIONS

Half or more of recurrent shunt infections were with organisms different from the original organism, and hence were new-type infections introduced during the management of the original infections. Incomplete eradication of original pathogens accounted for 3 (21.4%) of the 14 recurrent infections. Reusing recently infected or contaminated ventricular entry sites, both for CSF drainage during treatment and for implantation of new shunts, was as safe, with regard to risk of recurrent infection, as switching to new entry sites. Prior evidence of shunt infection is not, alone, a sufficient reason to change to a previously well-functioning site, and reuse of contaminated ventricular entry sites avoids all risks associated with making new ventricular entries.

Ventriculosubgaleal shunt in the treatment of posthemorrhagic and postinfectious hydrocephalus of premature infants

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).

Neonatal posthemorrhagic hydrocephalus from prematurity: pathophysiology and current treatment concepts

OBJECT

Preterm infants are at risk for perinatal complications, including germinal matrix-intraventricular hemorrhage (IVH) and subsequent posthemorrhagic hydrocephalus (PHH). This review summarizes the current understanding of the epidemiology, pathophysiology, management, and outcomes of IVH and PHH in preterm infants.

METHODS

The MEDLINE database was systematically searched using terms related to IVH, PHH, and relevant neurosurgical procedures to identify publications in the English medical literature. To complement information from the systematic search, pertinent articles were selected from the references of articles identified in the initial search.

RESULTS

This review summarizes the current knowledge regarding the epidemiology and pathophysiology of IVH and PHH, primarily using evidence-based studies. Advances in obstetrics and neonatology over the past few decades have contributed to a marked improvement in the survival of preterm infants, and neurological morbidity is also starting to decrease. The incidence of IVH is declining, and the incidence of PHH will likely follow. Currently, approximately 15% of preterm infants who suffer severe IVH will require permanent CSF diversion. The clinical presentation and surgical management of symptomatic PHH with temporary ventricular reservoirs (ventricular access devices) and ventriculosubgaleal shunts and permanent ventriculoperitoneal shunts are discussed. Preterm infants who develop PHH that requires surgical treatment remain at high risk for other related neurological problems, including cerebral palsy, epilepsy, and cognitive and behavioral delay. This review highlights numerous opportunities for further study to improve the care of these children.

CONCLUSIONS

A better grasp of the pathophysiology of IVH is beginning to impact the incidence of IVH and PHH. Neonatologists conduct rigorous Class I and II studies to advance the outcomes of preterm infants. The need for well-designed multicenter trials is essential because of the declining incidence of IVH and PHH, variations in referral patterns, and neonatal ICU and neurosurgical management. Well-designed multicenter trials will eventually produce evidence to enable neurosurgeons to provide their smallest, most vulnerable patients with the best practices to minimize perioperative complications and permanent shunt dependence, and most importantly, optimize long-term neurodevelopmental outcomes.

Ventricular access devices are safe and effective in the treatment of posthemorrhagic ventricular dilatation prior to shunt placement

Intraventricular hemorrhage of prematurity (IVH) is a diagnosis that has become more frequent in recent years. Advances in medical care have led to survival of increasingly premature infants, as well as infants with more complex medical conditions. Treatment with a ventricular access device (VAD) was reported almost 3 decades ago; however, it is unclear how effective this treatment is in the current population of premature infants. At our institution (from 2004 to present), we treat posthemorrhagic hydrocephalus (PHH) with a VAD. In order to look at safety and efficacy, we retrospectively combed the medical records of premature children, admitted to Lucile Packard Children's Hospital from January 2005 to December 2009, and identified 310 premature children with IVH. Of these, 28 children required treatment for PHH with a VAD. There were no infections associated with placement of these devices and a very low rate of other complications, such as need for repositioning (7.41%) or replacement (3.75%). Our data show that treatment with a VAD is very safe, with few complications and can be used to treat PHH in this very complex infant population.

Neurosurgical treatment of progressive posthemorrhagic ventricular dilation in preterm infants: a 10-year single-institution study

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.

Ventriculosubgaleal shunting for post-haemorrhagic hydrocephalus in premature neonates

BACKGROUND

The management of hydrocephalus secondary to intraventricular haemorrhage in neonates can be controversial. Temporary diversion of cerebrospinal fluid (CSF) is often required due to the low birth weight and high risks of shunting in these patients. Ventriculosubgaleal (VSG) CSF diversion is an effective way of achieving this goal whilst minimising the risks of complications. It is a well-described technique but is rarely used in contemporary neurosurgical practice.

METHODS

Nine neonates treated with VSG shunting for post-haemorrhagic hydrocephalus were assessed. Gestational age, birth weight, duration of treatment efficacy, requirement for permanent shunting and complications were recorded.

RESULTS

In all 9 patients, the VSG shunt controlled the progression of hydrocephalus. A permanent shunt was avoided in 2 patients. One patient required revision of the subgaleal shunt to extend the interval to the insertion of a permanent shunt. None of the patients developed any CSF infection or leak.

CONCLUSION

VSG CSF diversion offers a simple, effective and relatively safe means of treating hydrocephalus in the neonate, with a low risk of complications and the possibility of avoiding permanent shunting.

Ventriculosubgaleal shunts at Columbus Children's Hospital: Neurosurgical implant placement in the neonatal intensive care unit

OBJECT

The authors review all cases in which ventriculosubgaleal (VSG) shunts were placed at Columbus Children's Hospital for the treatment of posthemorrhagic hydrocephalus in order to assess the surgical procedure, effectiveness of surgery, and complications of cerebrospinal fluid diversion to the subgaleal space. The purpose of the review is to make a comparison between cases in which shunts were placed in the operating room (OR) and those in which they were placed in the neonatal intensive care unit (NICU). Considerations and complications specific to patient transport to the OR or surgical implantation in the NICU are discussed.

METHODS

Seventeen infants with posthemorrhagic hydrocephalus were treated with VSG shunt placement over a period of 4 years. A retrospective analysis of these cases was performed to evaluate multiple aspects of the procedure. Specifically, the surgical procedure, duration of shunt function prior to shunt conversion, neuroimaging changes, operative complications, and risk of infection are discussed. The authors also performed a comparative analysis of shunt placement in the NICU and the OR.

RESULTS

The length of the procedure was similar in the two locations. No differences in perioperative or intraoperative risks and no increased risk of infection were seen in either location in this pilot study. Interestingly, the mean lifespan of primary implants placed in the NICU (73 days) was longer than that of those placed in the OR (43 days).

CONCLUSIONS

Ventriculosubgaleal shunt placement offers a safe and effective temporary means of treating post-hemorrhagic hydrocephalus and can be reliably and safely performed at the bedside.

Shunts vs endoscopic third ventriculostomy in infants: are there different types and/or rates of complications? A review

INTRODUCTION

The decision-making process when we compare endoscopic third ventriculostomy (ETV) with shunts as surgical options for the treatment of hydrocephalus in infants is conditioned by the incidence of specific and shared complications of the two surgical procedures.

REVIEW

Our literature review shows that the advantages of ETV in terms of complications are almost all related to two factors: (a) the avoidance of a foreign body implantation and (b) the establishment of a 'physiological' cerebrospinal fluid (CSF) circulation. Both these kinds of achievements are particularly important in infants because of the relative high rate of some intraoperative (i.e. abdominal) and late (secondary craniosynostosis, slit-ventricle syndrome) shunt complications in this specific subset of patients. On the other side, the main factor which is claimed against ETV is the relatively high risk of immediate mortality and neurological complications. Clinical manifestations of neurological structure damage seem to be more frequent in infants, probably due to the more relevant effect of parenchymal and vascular damage in this age group; however, both the immediate mortality and neurological damage risk of ETV procedures should be weighted against the long-term mortality and the late neurological damage which is not infrequently described as a consequence of shunt malfunction and proximal shunt revision procedures. Infections are possible in both ETV and extrathecal CSF procedures, especially in infants. However, the incidence of infective complications is significantly lower in case of ETV (1-5% vs 1-20%). Moreover, different from shunting procedures, infections in children with third ventriculostomy have a more benign course, being generally controlled by antibiotic treatment alone.

Insights into the pathogenesis of hydrocephalus from transgenic and experimental animal models

Hydrocephalus is a progressive brain disorder characterized by abnormalities in the flow of cerebrospinal fluid (CSF) and ventricular dilatation that leads to cerebral atrophy, and if left untreated, can be fatal. Genetic mutations, congenital malformations, infectious diseases, intracerebral hemorrhages and tumors are common conditions resulting in hydrocephalus. Although the causes of obstructive hydrocephalus are better understood, the mechanisms resulting in chronic, progressive communicating congenital and acquired hydrocephalus are less well understood. In this regard, recent studies in transgenic (tg) mice suggest that increased expression of cytokines such as TGF-beta1 might play an important role by disrupting the vascular extracellular matrix (ECM) remodeling, promoting hemorrhages, and altering the reabsorption of CSF. In this context, the main objective of this manuscript is to provide an overview on the cellular and molecular mechanisms of hydrocephalus based on studies derived from tg and experimental animal models.