Shunt revision rates in myelomeningocele patients in the first year of life: a retrospective study of 52 patients

Intracranial volumetric evaluation in postnatally repaired myelomeningocele infants

INTRODUCTION

Most myelomeningocele (MMC) cases present with ventriculomegaly or hydrocephalus, yet a comprehensive volumetric assessment of MMC intracranial structures is lacking. This study aimed to provide baseline data on intracranial structural volumes immediately after birth in MMC infants who underwent repair surgeries after birth (postnatal repair).

METHODS

In this retrospective single-center study, we analyzed 52 MMC infants undergoing postnatal repair, utilizing head computed tomography scans at birth for volumetric assessment. Intracranial volume (ICV), lateral ventricles volume (LVV), choroid plexus volume (CPV), and posterior cranial fossa volume (PCFV) were measured. Hydrocephalus was classified into no hydrocephalus, progressive hydrocephalus, and hydrocephalus at birth. Comparative analysis employed the Wilcoxon rank-sum test. Receiver operating characteristic (ROC) analysis discriminated cases with and without ventriculoperitoneal shunt (VPS).

RESULTS

The median values were 407.50 mL for ICV, 33.18 mL for LVV, 0.67 mL for CPV, and 21.35 mL for PCFV. Thirty-seven cases (71.15%) underwent VPS. ROC analysis revealed an LVV cut-off value of 6.74 mL for discriminating cases with and without VPS. Progressive hydrocephalus showed no significant difference in ICV but significantly larger LVV compared to no hydrocephalus. Hydrocephalus at birth demonstrated statistically larger ICV and LVV compared to the other two types.

CONCLUSION

Baseline volumetric data were provided, and volumetric analysis exhibited statistical differences among three hydrocephalus types. These findings enhance our understanding of intracranial volumetric changes in MMC, facilitating more objective assessments of MMC cases.

Somatic Development Disorders in Children and Adolescents Affected by Syndromes and Diseases Associated with Neurodysfunction and Hydrocephalus Treated/Untreated Surgically

Background: This study was conducted to evaluate the co-occurrence of hydrocephalus treated/untreated surgically and congenital nervous system disorders or neurological syndromes with symptoms visible since childhood, and with somatic development disorders, based on significant data obtained during admission to a neurological rehabilitation unit for children and adolescents. Methods: The study applied a retrospective analysis of data collected during hospitalization of 327 children and adolescents, aged 4−18 years, all presenting congenital disorders of the nervous system and/or neurological syndromes associated with at least one neurodysfunction that existed from early childhood. To allow the identification of individuals with somatic development disorders in the group of children and adolescents with hydrocephalus treated/untreated surgically, the adopted criteria considered the z-score values for body height, body weight, head circumference, body mass index, and head circumference index. Results: Treated/untreated hydrocephalus was observed in the study group at the rates of 8% and 0.9%, respectively. Among 239 patients with cerebral palsy, 9 (3.8%) had surgically treated hydrocephalus, 17 (70.8%) of 24 patients with neural tube defects also had hydrocephalus treated with surgery, and 3 (12.5%) of 24 patients with neural tube defects had untreated hydrocephalus. This medical condition was a more frequent comorbidity in subjects with neural tube defects compared with those with cerebral palsy (p < 0.001). Subjects with untreated hydrocephalus most frequently presented macrocephaly (p < 0.001), including absolute macrocephaly (p = 0.001), and with tall stature (p = 0.007). Excessive body mass co-occurred more frequently with surgically untreated hydrocephalus, but the relationship was not statistically significant (p = 0.098). Conclusions: Surgically treated hydrocephalus occurred in patients with cerebral palsy and neural tube defects, and untreated hydrocephalus was present only in patients with neural tube defects. Untreated hydrocephalus negatively changed the course of individual development in the studied group of children, in contrast to surgically treated hydrocephalus.

Early Outcome of Endoscopic Third Ventriculostomy With Choroid Plexus Cauterization Versus Ventriculoperitoneal Shunt as Primary Treatment of Hydrocephalus in Children With Myelomeningocele: A Prospective Cohort Study

BACKGROUND

Myelomeningocele is associated with hydrocephalus in 35% to 90% of cases. Hydrocephalus is usually treated with insertion of ventriculoperitoneal shunt; however, there is growing evidence that endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) is an alternative.

OBJECTIVE

To compare the success rate and morbidity of ETV with CPC and ventriculoperitoneal shunt (VPS) as the primary treatment of hydrocephalus in patients with myelomeningocele.

METHODS

A prospective study from January 2016 to February 2019, involving 46 patients with myelomeningocele who developed hydrocephalus after repair in a tertiary hospital in southwestern Nigeria. Biodata and preoperative features of hydrocephalus were documented. ETV + CPC or VPS was done using standard operative techniques. Patients were followed up monthly for 6 mo.

RESULTS

There were 23 patients in the ETV + CPC arm and 22 patients in the VPS arm. Morbidities were cerebrospinal fluid leak, 8.3% in the ETV + CPC arm and 4.5% in the VPS arm, wound dehiscence, 13.6% in the VPS arm, none in the ETV + CPC arm. At 6-mo follow-up, success rate for ETV + CPC was 60.9% and 59.1% for VPS, P = .9.

CONCLUSION

ETV + CPC had similar success rate with VPS at 6 mo with lower morbidity. ETV + CPC should be considered a viable alternative when treating patients with myelomeningocele and hydrocephalus.

Acellular Dermal Matrix as a Definitive Reconstructive Option for Management of a Large Myelomeningocele Defect in the Setting of Severe Lumbar Kyphosis

BACKGROUND

Severe kyphosis is infrequently seen in neonates with myelomeningoceles. Spinal skeletal dysmorphology complicates repair, as local tissue may be insufficient to cover the dural repair. Although neonatal kyphectomy has been proposed as a potential solution to this problem, it carries significant potential risks that may not be acceptable to families.

CASE DESCRIPTION

A neonate presented with a large myelomeningocele defect with associated severe lumbar kyphosis. Kyphectomy was both declined by the family owing to the potential surgical risks and deemed not appropriate by the surgeons based on the challenging anatomic considerations. Soft tissue closure was not possible with local tissue rearrangement. Acellular dermal matrix was used as a definitive soft tissue coverage option, with complete epithelialization noted at 8 weeks postoperatively.

CONCLUSIONS

Acellular dermal matrix is a potentially useful adjunct for definitive reconstruction of complex neonatal soft tissue defects where local tissue is not available.

Experience in shunt management on revision free survival in infants with myelomeningocele

OBJECTIVE

Depending on the etiology of hydrocephalus in childhood, the shunt therapy still remains challenging due to frequent shunt complications leading to possible revisions such as shunt infection or shunt malfunction. In myelomeningocele (MMC) patients who often require shunt therapy, higher revisions rates were reported. In a single-center retrospective study, experiences on shunt regimen on hydrocephalus associated with MMC are presented.

METHODS

Data of 160 infant hydrocephalus cases younger than 1 year of age at the time of implantation were retrospectively reviewed from the hospital database. These patients received an adjustable differential pressure valve with gravitational unit and antibiotic impregnated catheters as a primary or secondary implant during the time period of April 2007 to July 2015. The subgroup of infants cases with MMC (n = 44; age 50.6 ± 80.6 days) were compared to the remaining cohort of other hydrocephalus etiology (control group). The shunt and valve revision free survival rates were recorded until July 2017.

RESULTS

During the mean follow-up of 48.7 ± 19.2 (7-114) months, the shunt revision free survival was 87% at 1 year and 49% at 60 months in the MMC cohort. The control group showed a shunt survival rate of 68% at 1 year and 39% at 60 months. Similarly, the valve revision free survival rate showed a significant higher rate of 92% at 1 year and 69% at 60 months in the MMC group compared to the control group (75% at 1 year and 51% at 60 months; p < 0.05). During the entire follow-up period, 37% of the MMC infants underwent a revision operation in contrast to the control group of 40%.

CONCLUSION

The presented shunt strategy showed improved revision free survival rates in infants with a MMC-related hydrocephalus in comparison to other etiologies of hydrocephalus in infants, which might relate to infection prophylaxis and high drainage resistance integrated in the shunt system.