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Hamilton K, Brandmeir N, Adelson PD. Use of an Irrigating External Ventricular Drain in an Infant: Proof-Of-Concept Technical Note. World Neurosurg 2024; 189:174-180. [PMID: 38878895 DOI: 10.1016/j.wneu.2024.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 06/09/2024] [Indexed: 07/09/2024]
Abstract
OBJECTIVE This report describes the procedural nuances for use of an irrigating external ventricular drain (EVD) in an infant patient. Intraventricular hemorrhage (IVH) and other intraventricular pathologies, such as infection, can occur in a variety of situations and patient populations, with few interventions available for immediate resolution. While manual endoscopic surgical irrigation has been trialed in both adult and pediatric patient populations to clear blood products or debris, this concept has recently been further extrapolated to the use of a continuous irrigating EVD over a more extended period. While this technique has been more commonly used for subarachnoid hemorrhage in adults, study of its use in pediatric patients, particularly in infants, is lacking. METHODS In this single case technical note of proof of feasibility, a continuous irrigating EVD was used in an infant to help clear an iatrogenic IVH. RESULTS Utilization of an irrigating EVD was successfully completed in a 9 kg infant without associated complications. Clearance of IVH was noted after 9 days of irrigation. CONCLUSIONS Use of irrigating EVD catheters should not be limited to the adult population. Indications for use are broad in the pediatric population and warrant further exploration.
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Affiliation(s)
- Kimberly Hamilton
- Neurosurgery Department, West Virginia University, Morgantown, West Virginia, USA.
| | - Nick Brandmeir
- Neurosurgery Department, West Virginia University, Morgantown, West Virginia, USA
| | - P David Adelson
- Neurosurgery Department, West Virginia University, Morgantown, West Virginia, USA
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Wassef CE, Thomale UW, LoPresti MA, DeCuypere MG, Raskin JS, Mukherjee S, Aquilina K, Lam SK. Experience in endoscope choice for neuroendoscopic lavage for intraventricular hemorrhage of prematurity: a systematic review. Childs Nerv Syst 2024:10.1007/s00381-024-06408-6. [PMID: 38801444 DOI: 10.1007/s00381-024-06408-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/13/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE Intraventricular hemorrhage (IVH) of prematurity occurs in 20-38% of infants born < 28 weeks gestational age and 15% of infants born in 28-32 weeks gestational age. Treatment has evolved from conservative management and CSF diversion of temporizing and shunting procedures to include strategies aimed at primarily clearing intraventricular blood products. Neuroendoscopic lavage (NEL) aims to decrease the intraventricular blood burden under the same anesthetic as temporizing CSF diversion measures in cases of hydrocephalus from IVH of prematurity. Given the variety of neuroendoscopes, we sought to review the literature and practical considerations to help guide neuroendoscope selection when planning NEL. METHODS We conducted a systematic review of the literature on neuroendoscopic lavage in IVH of prematurity to examine data on the choice of neuroendoscope and outcomes regarding shunt rate. We then collected manufacturer data on neuroendoscopic devices, including inflow and outflow mechanisms, working channel specifications, and tools compatible with the working channel. We paired this information with the advantages and disadvantages reported in the literature and observations from the experiences of pediatric neurosurgeons from several institutions to provide a pragmatic evaluation of international clinical experience with each neuroendoscope in NEL. RESULTS Eight studies were identified; four neuroendoscopes have been used for NEL as reported in the literature. These include the Karl Storz Flexible Neuroendoscope, LOTTA® system, GAAB system, and Aesculap MINOP® system. The LOTTA® and MINOP® systems were similar in setup and instrument options. Positive neuroendoscope features for NEL include increased degrees of visualization, better visualization with the evolution of light and camera sources, the ability to sterilize with autoclave processes, balanced inflow and outflow mechanisms via separate channels, and a working channel. Neuroendoscope disadvantages for NEL may include special sterilization requirements, large outer diameter, and limitations in working channels. CONCLUSIONS A neuroendoscope integrating continuous irrigation, characterized by measured inflow and outflow via separate channels and multiple associated instruments, appears to be the most commonly used technology in the literature. As neuroendoscopes evolve, maximizing clear visualization, adequate inflow, measured outflow, and large enough working channels for paired instrumentation while minimizing the footprint of the outer diameter will be most advantageous when applied for NEL in premature infants.
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Affiliation(s)
- Catherine E Wassef
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Ulrich W Thomale
- Pediatric Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Melissa A LoPresti
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Michael G DeCuypere
- Division of Pediatric Neurosurgery, Lurie Children's Hospital, 225 E Chicago Ave, Box 28, Chicago, IL, 60611, USA
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey S Raskin
- Division of Pediatric Neurosurgery, Lurie Children's Hospital, 225 E Chicago Ave, Box 28, Chicago, IL, 60611, USA
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Shreya Mukherjee
- Division of Pediatric Neurosurgery, Lurie Children's Hospital, 225 E Chicago Ave, Box 28, Chicago, IL, 60611, USA
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kristian Aquilina
- Department of Pediatric Neurosurgery, Great Ormond Street Hospital, London, UK
| | - Sandi K Lam
- Division of Pediatric Neurosurgery, Lurie Children's Hospital, 225 E Chicago Ave, Box 28, Chicago, IL, 60611, USA.
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Hall BJ, Duddy JC, Apostolopoulou K, Pettorini B. A tailored approach to the management of post-haemorrhagic hydrocephalus. Childs Nerv Syst 2024; 40:665-671. [PMID: 37952209 PMCID: PMC10891183 DOI: 10.1007/s00381-023-06214-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/03/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE Neuro-endoscopic lavage (NEL) is an increasingly popular intervention for intraventricular haemorrhage (IVH) and post-haemorrhagic hydrocephalus (PHH), with considerable variation in technique dependent on clinician and clinical circumstances. Whilst efforts to standardise the technique are ongoing, this work describes a tertiary centre experience utilising NEL, highlighting potential caveats to standardisation. METHODS A retrospective review of electronic case notes for patients undergoing temporising surgical intervention for IVH between 2012 and 2021 at our centre was performed. Data collected included (i) gestational age, (ii) aetiology of hydrocephalus, (iii) age at time of intervention, (iv) intervention performed, (v) need for permanent CSF diversion, (vi) 'surgical burden', i.e. number of procedures following primary intervention, and (vii) wound failure and infection rate. Data was handled in Microsoft Excel and statistical analysis SPSS v27.0 RESULTS: 49 neonates (n = 25 males) were included. Overall mean gestational age was 27 weeks and at intervention 35 + 3 weeks. IVH was the predominant cause of hydrocephalus (93.8%) and primary surgical interventions included insertion of a ventriculosubgaleal shunt (VSGS) in n = 41 (83.6%) patients, NEL in n = 6 (12.2%) patients and insertion of an EVD in n = 2 (4.1%). N = 9 (18.4%) patients underwent NEL at some point during the time interval reviewed; n = 4 (8.2%) received NEL monotherapy and n = 5 (10.2%) also received a VSGS. Rate of conversion to definitive CSF diversion between NEL (n = 8, 88.9%) and VSGS cohorts (n = 37, 92.5%) was not significantly different (p = 0.57), nor between NEL alone (n = 3, 75%) and NEL + VSGS (n = 5, 100%) (p = 0.44). None of the patients that underwent NEL monotherapy had any wound issues or CNS infection as a result of the initial intervention, compared to n = 3 (60%) of those that underwent NEL and implantation of VSGS (p = 0.1). CONCLUSION Both NEL and VSGS are effective in temporising hydrocephalus in neonates, occasionally offering a definitive solution in and of themselves. The benefit of dual therapy however remains to be seen, with the addition of VSGS potentially increasing the risk of wound failure in an already vulnerable cohort.
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Affiliation(s)
- Benjamin J Hall
- Department of Neurosurgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK.
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK.
- Institute of Infection, Veterinary and Ecological Sciences (IVES), The University of Liverpool, Liverpool, UK.
| | - John C Duddy
- Department of Neurosurgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - Katerina Apostolopoulou
- Department of Neurosurgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - Benedetta Pettorini
- Department of Neurosurgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
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Park YS. Treatment Strategies and Challenges to Avoid Cerebrospinal Fluid Shunting for Pediatric Hydrocephalus. Neurol Med Chir (Tokyo) 2022; 62:416-430. [PMID: 36031350 PMCID: PMC9534569 DOI: 10.2176/jns-nmc.2022-0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Treatment for pediatric hydrocephalus aims not only to shrink the enlarged ventricle morphologically but also to create an intracranial environment that provides the best neurocognitive development and to deal with various treatment-related problems over a long period of time. Although the primary diseases that cause hydrocephalus are diverse, the ventricular peritoneal shunt has been introduced as the standard treatment for several decades. Nevertheless, complications such as shunt infection and shunt malfunction are unavoidable; the prognosis of neurological function is severely affected by such factors, especially in newborns and infants. In recent years, treatment concepts have been attempted to avoid shunting, mainly in the context of pediatric cases. In this review, the current role of neuroendoscopic third ventriculostomy for noncommunicating hydrocephalus is discussed and a new therapeutic concept for post intraventricular hemorrhagic hydrocephalus in preterm infants is documented. To avoid shunt placement and achieve good neurodevelopmental outcomes for pediatric hydrocephalus, treatment modalities must be developed.
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Affiliation(s)
- Young-Soo Park
- Department of Neurosurgery and Children's Medical Center, Nara Medical University
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Huang J, Chen B. Value of CSF-Cl, CSF-GS, CSF-MALB, and CSF-ADA in Differential Diagnosis of Secondary Hydrocephalus. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:6742795. [PMID: 35685670 PMCID: PMC9167093 DOI: 10.1155/2022/6742795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/06/2022] [Accepted: 05/12/2022] [Indexed: 11/18/2022]
Abstract
Objectives To investigate the value of cerebrospinal fluid chloride (CSF-Cl), cerebrospinal fluid glucose (CSF-GS), cerebrospinal fluid microalbumin (CSF-MALB), and cerebrospinal fluid adenosine deaminase (CSF-ADA) in the differential diagnosis of secondary hydrocephalus. Methods 103 patients with secondary hydrocephalus treated in our hospital from January 2018 to April 2022 were selected. According to different types, it is divided into the hemorrhagic hydrocephalus group and tumor hydrocephalus group. By detecting the levels of inflammatory factors such as CSF-Cl, CSF-GS, CSF-MALB, and CSF-ADA in the two groups, we can analyze the value of these inflammatory factors in the differential diagnosis of secondary hydrocephalus. Results The level of CSF-MALB in the hemorrhagic hydrocephalus group was significantly higher than that in the tumor hydrocephalus group, and the difference between the two groups was statistically significant (P < 0.05). There was no significant difference in the levels of CSF-Cl, CSF-GS, and CSF-ADA between the two groups (P > 0.05). The area under ROC curve (AUC) of CSF-Cl, CSF-GS, CSF-MALB, and CSF-ADA in the differential diagnosis of secondary hydrocephalus was 0.438, 0.553, 0.750, and 0.542, respectively, sensitivity was 15.1%, 45.3%, 79.2%, and 18.9%, respectively, and specificity was 96.0%, 80.0%, 80.0%, and 94.0%, respectively. Conclusions The inflammatory reaction of hemorrhagic hydrocephalus was significantly greater than that of tumor hydrocephalus. Moreover, CSF-MALB is closely related to the pathogenesis of hemorrhagic hydrocephalus. At the same time, CSF-MALB can be used as a good index for rapid differential diagnosis of secondary hydrocephalus.
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Affiliation(s)
- Junzhang Huang
- Department of Neurosurgery, Guangdong Medical University, Zhanjiang City, Guangdong Province, China
| | - Bing Chen
- Department of Neurosurgery, Guangdong Medical University, Zhanjiang City, Guangdong Province, China
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Chari A. A standardised protocol for neuro-endoscopic lavage for post-haemorrhagic ventricular dilatation: A Delphi consensus approach. Childs Nerv Syst 2022; 38:2181-2187. [PMID: 36207447 PMCID: PMC9617835 DOI: 10.1007/s00381-022-05632-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 07/19/2022] [Indexed: 02/05/2023]
Abstract
Neuro-endoscopic lavage (NEL) has shown promise as an emerging procedure for intraventricular haemorrhage (IVH) and post-haemorrhagic ventricular dilatation (PHVD). However, there is considerable variation with regard to the indications, objectives, and surgical technique in NEL. There is currently no randomised trial evidence that supports the use of NEL in the context of PHVD. This study aims to form a consensus on technical variations in the indications and procedural steps of NEL. A mixed-methods modified Delphi consensus process was conducted between consultant paediatric neurosurgeons across the UK. Stages involved literature review, survey, focused online consultation, and iterative revisions until > 80% consensus was achieved. Twelve consultant paediatric neurosurgeons from 10 centres participated. A standardised protocol including indications, a 3-phase operative workflow (pre-ventricular, intraventricular, post-ventricular), and post-operative care was agreed upon by 100% of participants. Case- and surgeon-specific variation was considered and included through delineation of mandatory, optional, and not recommended steps. Expert consensus on a standardised protocol for NEL was achieved, delineating the surgical workflow into three phases such as pre-ventricular, intraventricular, and post-ventricular, each consisting of mandatory, optional, and not recommended steps. The work provides a platform for future trials, training, and implementation of NEL.
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Affiliation(s)
| | - Aswin Chari
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK
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