Extended Experience with Neuroendoscopic Lavage for Posthemorrhagic Hydrocephalus in Neonates

Use of an Irrigating External Ventricular Drain in an Infant: Proof-Of-Concept Technical Note

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.

Experience in endoscope choice for neuroendoscopic lavage for intraventricular hemorrhage of prematurity: a systematic review

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.

Neuroendoscopic Lavage and Third Ventriculostomy for the Treatment of Intraventricular Hemorrhage and Hydrocephalus in Neonates. A Prospective Study with 18 Months of Follow-Up

BACKGROUND

 Neonatal intraventricular hemorrhage (IVH) may evolve into posthemorrhagic hydrocephalus and cause neurodevelopmental impairment, becoming a common complication of premature infants, occurring in up to 40% of preterm infants weighing less than 1,500 g at birth. Around 10 to 15% of preterm infants develop severe (grades III-IV) IVH. These infants are at high risk of developing posthemorrhagic hydrocephalus. Neuroendoscopic lavage (NEL) is a suitable alternative for the management of this pathology. In this study, an endoscopic surgical approach directed toward the removal of intraventricular hematoma was evaluated for its safety and efficacy.

METHODS

 Between August 2016 and December 2019 (29 months), 14 neonates with posthemorrhagic hydrocephalus underwent NEL for removal of intraventricular blood by a single senior neurosurgeon. Complications such as reintervention and ventriculoperitoneal (VP) shunt placement were evaluated prospectively with an 18-month follow-up on average.

RESULTS

 In total, 14 neonates with IVH grades III and IV were prospectively recruited. Of these, six neonates did not need a VP shunt in the follow-up after neuroendoscopy (group 1), whereas eight neonates underwent a VP shunt placement (group 2). Nonsignificant difference between the groups was found concerning days after neuroendoscopy, clot extraction, third ventriculostomy, lamina terminalis fenestration, and septum pellucidum fenestration. In group 2, there was shunt dysfunction in five cases with shunt replacement in four cases.

CONCLUSION

 NEL is a feasible technique to remove intraventricular blood degradation products and residual hematoma in neonates suffering from posthemorrhagic hydrocephalus. In our series, endoscopic third ventriculostomy (ETV) + NEL could be effective in avoiding hydrocephalus after hemorrhage (no control group studied). Furthermore, patients without the necessity of VP-shunt had a better GMFCS in comparison with shunted patients.

Preterm-related posthemorrhagic hydrocephalus: Review of our institutional series with a long-term follow-up

INTRODUCTION

Preterm-related posthemorrhagic hydrocephalus is a major cause of neurological impairment and a common indication for a ventriculoperitoneal shunt in infants that are prone to diverse complications. Protocols of diagnosis and treatment are in continuous evolution and require evaluation of their results.

OBJECTIVE

To review the clinical characteristics and results of a series of preterm-related posthemorrhagic hydrocephalus needing a definitive shunt from 1982 to 2020 in our institution. As a secondary objective we evaluated the safety of the changes in our protocol of treatment from 2015.

METHODS

Retrospective review, clinical investigation.

RESULTS

133 patients were implanted a shunt in the study period. Shunt infection was diagnosed in 15 patients. Proximal shunt obstruction as the first complication was diagnosed in 30% of cases at one year, 37% at two years and 46% at five years. 61 patients developed very small or collapsed ventricles at last follow-up. Two thirds of our patients achieved normal neurological development or mild impairment. Changes in protocol did not significantly modify clinical results although improvement in most outcomes was observed. Mean follow-up was over nine years.

CONCLUSIONS

Clinical outcomes are comparable to previous reported data. Changes in protocol proved to be safe and improved our results. Programmable shunts can be used safely in preterm patients although they may not prevent tendency towards ventricular collapse, which is very common after long follow-up.

Is ventricular lavage a novel treatment of neonatal posthemorrhagic hydrocephalus? a meta analysis

INTRODUCTION

Intraventricular hemorrhage (IVH) may produce obliterative arachnoiditis, which disrupts the flow and absorption of cerebrospinal fluid (CSF), resulting in posthemorrhagic hydrocephalus (PHH). PHH gives a high risk of neurofunctional impairment. Ventricular lavage is the treatment of choice for PHH in neonates with IVH for decades. It is developing with the combination of fibrinolytic therapy, also called drainage, irrigation, and fibrinolytic therapy (DRIFT), and with the use of neuroendoscopic apparatus, also called neuroendoscopic lavage (NEL).

METHODS

This review is a meta-analysis using the PRISMA method guideline, including the clinical studies comparing ventricular lavage (VL) with standard treatment of PHH between 2000 and 2021.

RESULTS

VL group reduced the shunt dependency compared to standard treatment (OR = 0.22; 95CI 0.05 to 0.97; p = 0.05). VL group has less infection risk compared to the standard treatment group (RR = 0.20; 95CI 0.07 to 0.59; p < 0.05). The severe neurofunctional outcome is similar between the two groups (OR = 0.99; 95CI 0.13 to 7.23; p = 0.99). The early approach treatment group may give better neurofunctional outcomes compared to the late approach (OR = 0.14; 95CI 0.06 to 0.35; p < 0.05).

CONCLUSION

VL reduce the shunt dependency on the PHH, decreasing the shunt's related infection rate. The early ventricular lavage may give benefit for the neurocognitive outcome.

Treatment Strategies and Challenges to Avoid Cerebrospinal Fluid Shunting for Pediatric Hydrocephalus

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.

The role of blood product removal in intraventricular hemorrhage of prematurity: a meta-analysis of the clinical evidence

INTRODUCTION

Premature neonates have a high risk of intraventricular hemorrhage (IVH) at birth, the blood products of which activate inflammatory cascades that can cause hydrocephalus and long-term neurological morbidities and sequelae. However, there is no consensus for one treatment strategy. While the mainstay of treatment involves CSF diversion to reduce intracranial pressure, a number of interventions focus on blood product removal at various stages including extraventricular drains (EVD), intra-ventricular thrombolytics, drainage-irrigation-fibrinolytic therapy (DRIFT), and neuroendoscopic lavage (NEL).

METHODS

We performed a systematic review and meta-analysis to compare the risks and benefits commonly associated with active blood product removal treatment strategies. We searched MEDLINE, Embase, Scopus, Cochrane Library, and CINAHL databases through Dec 2020 for articles reporting on outcomes of EVDs, thrombolytics, DRIFT, and NEL. Outcomes of interest were rate of conversion to ventriculoperitoneal shunt (VPS), infection, mortality, secondary hemorrhage, and cognitive disability.

RESULTS

Of the 10,398 articles identified in the search, 23 full-text articles representing 22 cohorts and 530 patients were included for meta-analysis. These articles included retrospective, prospective, and randomized controlled studies on the use of EVDs (n = 7), thrombolytics (n = 8), DRIFT therapy (n = 3), and NEL (n = 5). Pooled rates of reported outcomes for EVD, thrombolytics, DRIFT, and NEL for ventriculoperitoneal shunt (VPS) placement were 51.1%, 43.3%, 34.3%, and 54.8%; for infection, 15.4%, 12.5%, 4.7%, and 11.0%; for mortality, 20.0%, 11.6%, 6.0%, and 4.9%; for secondary hemorrhage, 5.8%, 7.8%, 20.0%, and 6.9%; for cognitive impairment, 52.6%, 50.0%, 53.7%, and 50.9%. Meta-regression using type of treatment as a categorical covariate showed no effect of treatment modality on rate of VPS conversion or cognitive disability.

CONCLUSION

There was a significant effect of treatment modality on secondary hemorrhage and mortality; however, mortality was no longer significant after adjusting for year of publication. Re-hemorrhage rate was significantly higher for DRIFT (p < 0.001) but did not differ among the other modalities. NEL also had lower mortality relative to EVD (p < 0.001) and thrombolytics (p = 0.013), which was no longer significant after adjusting for year of publication. Thus, NEL appears to be safer than DRIFT in terms of risk of hemorrhage, and not different than other blood-product removal strategies in terms of mortality. Outcomes-in terms of shunting and cognitive impairment-did not differ. Later year of publication was predictive of lower rates of mortality, but not the other outcome variables. Further prospective and randomized studies will be necessary to directly compare NEL with other temporizing procedures.

Neuroendoscopic lavage for the management of neonatal post-haemorrhagic hydrocephalus: a retrospective series

INTRODUCTION

Intraventricular haemorrhage (IVH) is a common complication of preterm birth, and optimal treatment remains uncertain. Neuroendoscopic lavage (NEL) has gained interest as a method for removal of intraventricular haematoma, with outcomes suggesting it to be safe and potentially effective.

METHODS

A retrospective review was carried identifying infants who underwent NEL for post-IVH hydrocephalus at our institution. Data was extracted on patient baseline demographics, comorbidities, complications, re-operation requirement, and neurodevelopmental outcomes.

RESULTS

Twenty-six patients (17 male) were identified, who underwent NEL at a mean age of 39 weeks and 4 days. Eighteen patients underwent simultaneous endoscopic third ventriculostomy (ETV). Mean patient follow-up was 57.7 months ± 11.8 months. A total of 17/26 patients went on to require a ventriculoperitoneal shunt (VPS). Nine patients did not require further surgical management of hydrocephalus; all had been managed with NEL + ETV. The relative risk of requiring VPS with NEL + ETV compared with NEL alone was 0.500 (CI: 0.315-0.794; p = 0.0033). The 24-month survival rate of VPS inserted following NEL was 64.7%. Exactly 5/26 (19.2%) had post-procedure complications: 2 CSF leaks (7.7%), 2 infections (7.7%), and 1 rebleed within 72 h of NEL (3.8%). On long-term follow-up, 22/25 patients achieved good motor outcome, either walking independently or with mobility aids. A total of 8/15 children attended mainstream schooling with adaption.

DISCUSSION

NEL is safe and potentially efficacious treatment for neonatal IVH. The procedure may reduce shunt dependence and, for those who require CSF diversion, improve shunt survival. Neurodevelopmentally, good motor and cognitive outcome can be achieved.

A neonatal neuroNICU collaborative approach to neuromonitoring of posthemorrhagic ventricular dilation in preterm infants

Morbidity and mortality in prematurely born infants have significantly improved due to advancement in perinatal care, development of NeuroNICU collaborative multidisciplinary approaches, and evidence-based management protocols that have resulted from a better understanding of perinatal risk factors and neuroprotective treatments. In premature infants with intraventricular hemorrhage (IVH), the detrimental secondary effect of posthemorrhagic ventricular dilation (PHVD) on the neurodevelopmental outcome can be mitigated by surgical intervention, though management varies considerably across institutions. Any benefit derived from the use of neuromonitoring to optimize surgical timing and technique stands to improve neurodevelopmental outcome. In this review, we summarize (1) the approaches to surgical management of PHVD in preterm infants and outcome data; (2) neuromonitoring modalities and the effect of neurosurgical intervention on this data; (3) our resultant protocol for the monitoring and management of PHVD. In particular, our protocol incorporates cerebral near-infrared spectroscopy (NIRS) and transcranial doppler ultrasound (TCD) to better understand cerebral physiology and to enable the hypothesis-driven study of the management of PHVD. IMPACT: Review of the published literature concerning the use of near-infrared spectroscopy (NIRS) and a cerebral Doppler ultrasound to study the effect of cerebrospinal fluid drainage on infants with posthemorrhagic ventricular dilation. Presentation of our institution's evidence-based protocol for the use of NIRS and cerebral Doppler ultrasound to study the optimal neurosurgical treatment of posthemorrhagic ventricular dilation, an as yet inadequately studied area.

A standardised protocol for neuro-endoscopic lavage for post-haemorrhagic ventricular dilatation: A Delphi consensus approach

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.

Secondary Brain Injury Following Neonatal Intraventricular Hemorrhage: The Role of the Ciliated Ependyma

Intraventricular hemorrhage is recognized as a leading cause of hydrocephalus in the developed world and a key determinant of neurodevelopmental outcome following premature birth. Even in the absence of haemorrhagic infarction or posthaemorrhagic hydrocephalus, there is increasing evidence of neuropsychiatric and neurodevelopmental sequelae. The pathophysiology underlying this injury is thought to be due to a primary destructive and secondary developmental insult, but the exact mechanisms remain elusive and this has resulted in a paucity of therapeutic interventions. The presence of blood within the cerebrospinal fluid results in the loss of the delicate neurohumoral gradient within the developing brain, adversely impacting on the tightly regulated temporal and spatial control of cell proliferation and migration of the neural stem progenitor cells within the subventricular zone. In addition, haemolysis of the erythrocytes, associated with the release of clotting factors and leucocytes into the cerebrospinal (CSF), results in a toxic and inflammatory CSF microenvironment which is harmful to the periventricular tissues, resulting in damage and denudation of the multiciliated ependymal cells which line the choroid plexus and ventricular system. The ependyma plays a critical role in the developing brain and beyond, acting as both a protector and gatekeeper to the underlying parenchyma, controlling influx and efflux across the CSF to brain interstitial fluid interface. In this review I explore the hypothesis that damage and denudation of the ependymal layer at this critical juncture in the developing brain, seen following IVH, may adversely impact on the brain microenvironment, exposing the underlying periventricular tissues to toxic and inflammatory CSF, further exacerbating disordered activity within the subventricular zone (SVZ). By understanding the impact that intraventricular hemorrhage has on the microenvironment within the CSF, and the consequences that this has on the multiciliated ependymal cells which line the neuraxis, we can begin to develop and test novel therapeutic interventions to mitigate damage and reduce the associated morbidity.

Prediction of persistent ventricular dilation by initial ventriculomegaly and clot volume in a porcine model

OBJECTIVE

While intraventricular hemorrhage (IVH) is associated with posthemorrhagic ventricular dilation (PHVD), not all infants affected by high-grade IVH develop PHVD. The authors aimed to determine clot-associated predictors of PHVD in a porcine model by varying the amount and rate of direct intraventricular injection of whole autologous blood.

METHODS

Seven 1-week-old piglets underwent craniectomy and injection of autologous blood into the right lateral ventricle. They survived for a maximum of 28 days. MRI was performed prior to injection, immediately postoperatively, and every 7 days thereafter. T1-weighted, T2-weighted, and susceptibility-weighted imaging (SWI) sequences were used to segment ventricular and clot volumes. Spearman correlations were used to determine the relationship between blood and clot volumes and ventricular volumes over time.

RESULTS

The maximum ventricular volume was up to 12 times that of baseline. One animal developed acute hydrocephalus on day 4. All other animals survived until planned endpoints. The interaction between volume of blood injected and duration of injection was significantly associated with clot volume on the postoperative scan (p = 0.003) but not the amount of blood injected alone (p = 0.38). Initial postoperative and day 7 clot volumes, but not volume of blood injected, were correlated with maximum (p = 0.007 and 0.014) and terminal (p = 0.014 and 0.036) ventricular volumes. Initial postoperative ventricular volume was correlated with maximum and terminal ventricular volume (p = 0.007 and p = 0.014).

CONCLUSIONS

Initial postoperative, maximum, and terminal ventricular dilations were associated with the amount of clot formed, rather than the amount of blood injected. This supports the hypothesis that PHVD is determined by clot burden rather than the presence of blood products and allows further testing of early clot lysis to minimize PHVD risk.

Timing of Temporizing Neurosurgical Treatment in Relation to Shunting and Neurodevelopmental Outcomes in Posthemorrhagic Ventricular Dilatation of Prematurity: A Meta-analysis

OBJECTIVE

To determine the relationship between timing of initiation of temporizing neurosurgical treatment and rates of ventriculoperitoneal shunt (VPS) and neurodevelopmental impairment in premature infants with post-hemorrhagic ventricular dilatation (PHVD).

STUDY DESIGN

We searched MEDLINE, EMBASE, CINAHL, Web of Science, the Cochrane Database of Systematic Reviews, and the Cochrane Center Register of Controlled Trials for studies that reported on premature infants with PHVD who underwent a temporizing neurosurgical procedure. The timing of the temporizing neurosurgical procedure, gestational age, birth weight, outcomes of conversion to VPS, moderate-to-severe neurodevelopmental impairment, infection, temporizing neurosurgical procedure revision, and death at discharge were extracted.

RESULTS

Sixty-two full-length articles and 6 conference abstracts (n = 2533 patients) published through November 2020 were included. Pooled rate for conversion to VPS was 60.5% (95% CI, 54.9-65.8), moderate-severe neurodevelopmental impairment 34.8% (95% CI, 27.4-42.9), infection 8.2% (95% CI, 6.7-10.1), revision 14.6% (95% CI, 10.4-20.1), and death 12.9% (95% CI, 10.2-16.4). The average age at temporizing neurosurgical procedure was 24.2 ± 11.3 days. On meta-regression, older age at temporizing neurosurgical procedure was a predictor of conversion to VPS (P < .001) and neurodevelopmental impairment (P < .01). Later year of publication predicted increased survival (P < .01) and external ventricular drains were associated with more revisions (P = .001). Tests for heterogeneity reached significance for all outcomes and a qualitative review showed heterogeneity in the study inclusion and diagnosis criteria for PHVD and initiation of temporizing neurosurgical procedure.

CONCLUSIONS

Later timing of temporizing neurosurgical procedure predicted higher rates of conversion to VPS and moderate-severe neurodevelopmental impairment. Outcomes were often reported relative to the number of patients who underwent a temporizing neurosurgical procedure and the criteria for study inclusion and the initiation of temporizing neurosurgical procedure varied across institutions. There is need for more comprehensive outcome reporting that includes all infants with PHVD regardless of treatment.

Intraventricular Hemorrhage in Premature Infants: A Historical Review

Intraventricular hemorrhage (IVH) is common in premature newborns and poses a high risk for morbidity with lifelong disability. We searched the available literature for original and secondary literature regarding the epidemiology, pathogenesis, and treatment of IVH in order to trace changes in the management of this disease over time. We examined IVH pathogenesis and epidemiology and reviewed the history of medical and surgical treatment for intraventricular hemorrhage in preterm children. Initial medical management strategies aimed at correcting coagulopathy and eventually targeted mediators of perinatal instability including respiratory distress. Surgical management centered around cerebrospinal fluid diversion, initially through serial lumbar punctures, progressing to ventriculoperitoneal shunting, with more recent interventions addressing intraventricular clot burden. We provide a historical review of the evolution of treatment for IVH in newborns. While the management of IVH has grown significantly over time, IVH remains a common neurosurgical disease that continues to affect patient and caregiver quality of life and health care costs. Despite advances in treatment over more than a century, IVH remains a significant cause of morbidity and mortality in premature infants, and an understanding of past approaches may inform the development of new treatments.

Ultrasound-assisted neuroendoscopic lavage for intraventricular hemorrhage in a newborn: illustrative case

BACKGROUND

The optimal treatment for posthemorrhagic hydrocephalus in newborns has not been established yet. Moreover, despite many valid therapeutic alternatives, unfavorable neurodevelopmental outcomes are frequent. According to recent literature, these discouraging results could be related to secondary inflammatory damage of the white matter due to the gradual dissolution of the intraventricular hematoma, which should be removed.

OBSERVATIONS

Neuroendoscopic lavage (NEL) has proven to be a safe and reliable procedure, able to adequately remove the intraventricular clots and the products of blood degradation. To increase surgical control of the entire ventricular system, the authors illustrated a case in which they associated real-time transfontanellar ultrasound monitoring with NEL.

LESSONS

Coupling these two techniques, the authors performed a rapid ventricular wash and obtained intraoperative confirmation of complete and accurate clot removal.

White matter injury in infants with intraventricular haemorrhage: mechanisms and therapies

Intraventricular haemorrhage (IVH) continues to be a major complication of prematurity that can result in cerebral palsy and cognitive impairment in survivors. No optimal therapy exists to prevent IVH or to treat its consequences. IVH varies in severity and can present as a bleed confined to the germinal matrix, small-to-large IVH or periventricular haemorrhagic infarction. Moderate-to-severe haemorrhage dilates the ventricle and damages the periventricular white matter. This white matter injury results from a constellation of blood-induced pathological reactions, including oxidative stress, glutamate excitotoxicity, inflammation, perturbed signalling pathways and remodelling of the extracellular matrix. Potential therapies for IVH are currently undergoing investigation in preclinical models and evidence from clinical trials suggests that stem cell treatment and/or endoscopic removal of clots from the cerebral ventricles could transform the outcome of infants with IVH. This Review presents an integrated view of new insights into the mechanisms underlying white matter injury in premature infants with IVH and highlights the importance of early detection of disability and immediate intervention in optimizing the outcomes of IVH survivors.

Neuroendoscopic surgery in neonates - indication and results over a 10-year practice

PURPOSE

Neuroendoscopic procedures for treatment of term and preterm newborn infants, such as endoscopic lavage for posthemorrhagic hydrocephalus, are gaining popularity despite sparse data. This single-institution report compiles all neuroendoscopic surgical procedures performed in neonates during a 10-year period.

METHODS

Charts and electronic records were reviewed of all consecutive newborns who underwent a neuroendoscopic procedure before reaching a postmenstrual age of 44 weeks between 09/2010 and 09/2020. Available documentation was reviewed regarding the performed neuroendoscopic procedure, course of disease, complications, and all re-operations throughout the first year of life.

RESULTS

During the 10-year study period, 116 infants (median gestational age at birth: 29 ¹/7 weeks) underwent a total of 153 neuroendoscopic procedures (median postmenstrual age at surgery: 35 ⁰/7 weeks). The most common indication at the time of the neuroendoscopic procedures (n = 153) was intraventricular hemorrhage (IVH, n = 119), intraventricular infection (n = 15), congenital malformation (n = 8), isolated 4th ventricle (n = 7), multiloculated hydrocephalus (n = 3), and tumor (n = 1). Thirty-eight of 116 children (32.8%) underwent 43 operative revisions after 153 neuroendoscopic procedure (28.1%). Observed complications requiring surgical revision were secondary infection (n = 11), CSF fistula (n = 9), shunt dysfunction (n = 8), failure of ETV (n = 6), among others. 72 children (62%) of 116 children required permanent CSF diversion via a shunt. The respective shunt rates per diagnosis were 47 of 80 (58.8%) for previously untreated IVH, 11 of 13 (84.6%) for intraventricular infection. Shunt survival rate for the first year of life was 74% for the whole cohort.

CONCLUSION

The experience with this large cohort of neonates demonstrates the feasibility of neuroendoscopic technique for the treatment of posthemorrhagic or postinfectious hydrocephalus. Rate and type of complications after neuroendoscopic procedures were within the expected range. Assessing the potential long-term benefits of neuroendoscopic techniques has to await results of ongoing studies.

Integrated understanding of hydrocephalus - a practical approach for a complex disease

Most of childhood hydrocephalus are originating during infancy. It is considered to be a complex disease since it is developed on the basis of heterogeneous pathophysiological mechanisms and different pathological conditions as well as during different age groups. Hence, it is of relevant importance to have a practical concept in mind, how to categorize hydrocephalus to surgically better approach this disease. The current review should offer further basis of discussion on a disease still most frequently seen in Pediatric Neurosurgery. Current literature on pathophysiology and classification of pediatric hydrocephalus has been reviewed to integrate the different published concepts of hydrocephalus for pediatric neurosurgeons. The current understanding of infant and childhood hydrocephalus pathophysiology is summarized. A simplified concept based on seven factors of CSF dynamics is elaborated and discussed in the context of recent discussions. The seven factors such as pulsatility, CSF production, major CSF pathways, minor CSF pathways, CSF absorption, venous outflow, and respiration may have different relevance and may also overlap for the individual hydrocephalic condition. The surgical options available for pediatric neurosurgeons to approach hydrocephalus must be adapted to the individual condition. The heterogeneity of hydrocephalus causes mostly developing during infancy warrant a simplified overview and understanding for an everyday approach. The proposed guide may be a basis for further discussion and may serve for a more or less simple categorization to better approach hydrocephalus as a pathophysiological complex disease.

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.

Intraventricular haemorrhage and posthaemorrhagic ventricular dilatation: moving beyond CSF diversion

Advances in medical care have led to more premature babies surviving the neonatal period. In these babies, germinal matrix haemorrhage (GMH), intraventricular haemorrhage (IVH) and posthaemorrhagic ventricular dilatation (PHVD) are the most important determinants of long-term cognitive and developmental outcomes. In this review, we discuss current neurosurgical management of IVH and PHVD, including the importance of early diagnosis of PHVD, thresholds for intervention, options for early management through the use of temporising measures and subsequent definitive CSF diversion. We also discuss treatment options for the evolving paradigm to manage intraventricular blood and its breakdown products. We review the evidence for techniques such as drainage, irrigation, fibrinolytic therapy (DRIFT) and neuroendoscopic lavage in the context of optimising cognitive, neurodevelopmental and quality of life outcomes in these premature infants.

TROPHY registry - status report

INTRODUCTION

The TROPHY registry has been established to conduct an international multicenter prospective data collection on the surgical management of neonatal intraventricular hemorrhage (IVH)-related hydrocephalus to possibly contribute to future guidelines. The registry allows comparing the techniques established to treat hydrocephalus, such as external ventricular drainage (EVD), ventricular access device (VAD), ventricular subgaleal shunt (VSGS), and neuroendoscopic lavage (NEL). This first status report of the registry presents the results of the standard of care survey of participating centers assessed upon online registration.

METHODS

On the standard of treatment forms, each center indicated the institutional protocol of interventions performed for neonatal post-hemorrhagic hydrocephalus (nPHH) for a time period of 2 years (Y1 and Y2) before starting the active participation in the registry. In addition, the amount of patients enrolled so far and allocated to a treatment approach are reported.

RESULTS

According to the standard of treatment forms completed by 56 registered centers, fewer EVDs (Y1 55% Y2 46%) were used while more centers have implemented NEL (Y1 39%; Y2 52%) to treat nPHH. VAD (Y1 66%; Y2 66%) and VSGS (Y1 42%; Y2 41%) were used at a consistent rate during the 2 years. The majority of the centers used at least two different techniques to treat nPHH (43%), while 27% used only one technique, 21% used three, and 7% used even four different techniques. Patient data of 110 infants treated surgically between 9/2018 and 2/2021 (13% EVD, 15% VAD, 30% VSGS, and 43% NEL) were contributed by 29 centers.

CONCLUSIONS

Our results emphasize the varying strategies used for the treatment of nPHH. The international TROPHY registry has entered into a phase of growing patient recruitment. Further evaluation will be performed and published according to the registry protocol.

Endoscopic brainwash after clipping a ruptured aneurysm of the communicating segment of the intracranial carotid artery

Background:

Intracranial aneurysms are common vascular malformation occurring in 1-2% of the population and accounting for 80–85% of nontraumatic subarachnoid hemorrhages. About 10% of the ruptured aneurysm causing subarachnoid hemorrhage (SHA) develop intraventricular hemorrhage (IVH). In this scenario, the external ventricular drain (EVD) is a usual treatment for IVH. To reduce the time for the clot absorption, the neuroendoscopy with clot removal and ventricular irrigation is a feasible option, although not routinely used.

Case Description:

This 2D video shows a case of a 60-year-old female, with sudden headache associated with nausea and vomit. The brain angiotomography revealed aneurysm in the communicating segment of the left internal carotid artery, with 10.5 mm of diameter; also showed intraparenchymal, subarachnoid, and IVH, with a Fisher Modified Grade of 4 and a prompt aneurysm clipping and EVD were performed. Two days after the first surgical procedure, a neuroendoscopy was performed to remove the ventricular clots and improve the patient outcomes.

Conclusion:

In the presented case, at the 6^th postoperative month, the patient was Grade 1 in the Rankin Modified Scale and without hydrocephalus. This procedure can be used routinely as an additional tool to microsurgical clipping to improve patients outcome.

Neurodevelopmental outcome at 2 years after neuroendoscopic lavage in neonates with posthemorrhagic hydrocephalus

OBJECTIVE

A standardized guideline for treatment of posthemorrhagic hydrocephalus in premature infants is still missing. Because an early ventriculoperitoneal shunt surgery is avoided due to low body weight and fragility of the patients, the neurosurgical treatment focuses on temporary solutions for CSF diversion as a minimally invasive approach. Neuroendoscopic lavage (NEL) was additionally introduced for early elimination of intraventricular blood components to reduce possible subsequent complications such as shunt dependency, infection, and multiloculated hydrocephalus. The authors report their first experience regarding neurodevelopmental outcome after NEL in this patient cohort.

METHODS

In a single-center retrospective cohort study with 45 patients undergoing NEL, the authors measured neurocognitive development at 2 years with the Bayley Scales of Infant Development, 2nd Edition, Mental Developmental Index (BSID II MDI) and graded the ability to walk with the Gross Motor Function Classification System (GMFCS). They further recorded medication with antiepileptic drugs (AEDs) and quantified ventricular and brain volumes by using 3D MRI data sets.

RESULTS

Forty-four patients were alive at 2 years of age. Eight of 27 patients (30%) assessed revealed a fairly normal neurocognitive development (BSID II MDI ≥ 70), 28 of 36 patients (78%) were able to walk independently or with minimal aid (GMFCS 0-2), and 73% did not require AED treatment. Based on MR volume measurements, greater brain volume was positively correlated with BSID II MDI (rs = 0.52, 95% CI 0.08-0.79) and negatively with GMFCS (rs = -0.69, 95% CI -0.85 to -0.42). Based on Bayesian logistic regression, AED treatment, the presence of comorbidities, and also cerebellar pathology could be identified as relevant risk factors for both neurodevelopmental outcomes, increasing the odds more than 2-fold-but with limited precision in estimation.

CONCLUSIONS

Neuromotor outcome assessment after NEL is comparable to previously published drainage, irrigation, and fibrinolytic therapy (DRIFT) study results. A majority of NEL-treated patients showed independent mobility. Further validation of outcome measurements is warranted in an extended setup, as intended by the prospective international multicenter registry for treatment of posthemorrhagic hydrocephalus (TROPHY).

Neuroendoscopic lavage for the management of posthemorrhagic hydrocephalus in preterm infants: safety, effectivity, and lessons learned

OBJECTIVE

Treatment of posthemorrhagic hydrocephalus in preterm infants is a matter of debate among pediatric neurosurgeons. Neuroendoscopic lavage (NEL) has been proposed as a suitable technique for the management of this pathology. The authors present their experience with 46 patients treated with NEL after germinal matrix hemorrhage, describe their technique, and analyze the outcomes.

METHODS

A retrospective analysis of patients affected by grade III or IV intraventricular hemorrhage (IVH) treated with NEL was performed. Nonmodifiable risk factors such as gestational age, weight at birth, modified Papile grade, and intercurrent diseases were reviewed. Safety analysis was performed, evaluating the incidence of postoperative complications. Effectivity was measured using radiological (frontal horn index and white matter injury), CSF biochemical (proteins, blood, and cellularity), and clinical variables. Permanent shunt rate and shunt survival were analyzed. The motor outcome was measured using the Gross Motor Function Classification System (GMFCS) at 18-24 months, and the neurocognitive outcome was evaluated according to the grade of adaptation to schooling.

RESULTS

Forty-six patients met the inclusion criteria. Patients were treated with a single NEL in 21 cases, 2 lavages in 13 cases, and 3 lavages in 12 cases. The mean gestational age at birth was 30.04 weeks, and the mean weight at birth was 1671.86 g. Hyaline membrane disease was described in 4.8% of the cases, hematological sepsis in 43.47%, persistent ductus arteriosus in 23.9%, and necrotizing enterocolitis in 10.9% of the cases. Modified Papile grade III and IV IVHs were observed in 60.9% and 39.1% of the cases, respectively. Postoperative infection was diagnosed in 10 of the 46 cases, CSF leak in 6, and rebleeding in 3. The mean frontal horn index decreased from 49.54 mm to 45.50 mm after NEL. No white matter injury was observed in 18 of 46 patients, focal injury was described in 13 patients, and diffuse bilateral white matter injury was observed in 15 patients. All CSF biochemical levels improved after lavage. The shunt rate was 58.7%, and shunt survival at 1 year was 50%. GMFCS grades I, II, III, IV, and V were observed in 44.74%, 21.05%, 2.63%, 15.79%, and 15.79% of patients, respectively. Good neurocognitive results were observed in 53.3% of the cases.

CONCLUSIONS

Neuroendoscopic lavage was a suitable alternative for the management of IVH in preterm infants in our series. Good motor and neurocognitive results were achieved by this technique, and the permanent shunt rate was reduced compared with historical controls.

Bedside placement of ventricular access devices under local anaesthesia in neonates with posthaemorrhagic hydrocephalus: preliminary experience

PURPOSE

Posthaemorrhagic ventricular dilatation in preterm infants is primarily treated using temporising measures, of which the placement of a ventricular access device (VAD) is one option. Permanent shunt dependency rates are high, though vary widely. In order to improve the treatment burden and lower shunt dependency rates, we implemented several changes over the years. One of these changes involves the setting of the surgery from general anaesthesia in the OR to local anaesthesia in bed at the neonatal intensive care unit (NICU), which may seem counterintuitive to many. In this article, we describe our surgical technique and present the results of this regimen and compare it to our previous techniques.

METHODS

Retrospective study of a consecutive series of 37 neonates with posthaemorrhagic ventricular dilatation (PHVD) treated using a VAD, with a cohort I (n = 13) treated from 2004 to 2008 under general anaesthesia in the OR, cohort II (n = 11) treated from 2009 to 2013 under general anaesthesia in the NICU and cohort III (n = 13) treated from December 2013 to December 2017 under local anaesthesia on the NICU.

RESULTS

The overall infection rate was 14%; the VAD revision rate was 22% and did not differ significantly between the cohorts. Procedures under local anaesthesia never required conversion to general anaesthesia and were well tolerated. After an average of 33 tapping days, 38% of the neonates received a permanent ventriculoperitoneal (VP) shunt. The permanent VP shunt rate was 9% with VAD placement under local anaesthesia and 52% when performed under general anaesthesia (p = 0.02).

CONCLUSION

Bedside placement of VADs for PHVD under local anaesthesia in neonates is a low-risk, well-tolerated procedure that results in at least equal results to surgery performed under general anaesthesia and/or performed in an OR.

TROPHY registry study design: a prospective, international multicenter study for the surgical treatment of posthemorrhagic hydrocephalus in neonates

INTRODUCTION

Among children with hydrocephalus, neonates with intraventricular hemorrhage (IVH) and posthemorrhagic hydrocephalus (PH) are considered a group with one of the highest complication rates of treatment. Despite continued progress in neonatal care, a standardized and reliable guideline for surgical management is missing for this challenging condition. Thus, further research is warranted to compare common methods of surgical treatment. The introduction of neuroendoscopic lavage has precipitated the establishment of an international registry aimed at elaborating key elements of a standardized surgical treatment.

METHODS

The registry is designed as a multicenter, international, prospective data collection for neonates aged 41 weeks gestation, with an indication for surgical treatment for IVH with ventricular dilatation and progressive hydrocephalus. The following initial temporizing surgical interventions, each used as standard treatment at participating centers, will be compared: external ventricular drainage (EVD), ventricular access device (VAD), ventricular subgaleal shunt (VSGS), and neuroendoscopic lavage (NEL). Type of surgery, perioperative data including complications and mortality, subsequent shunt surgeries, ventricular size, and neurological outcome will be recorded at 6, 12, 36, and 60 months.

RESULTS

An online, password-protected website will be used to collect the prospective data in a synchronized manner. As a prospective registry, data collection will be ongoing, with no prespecified endpoint. A prespecified analysis will take place after a total of 100 patients in the NEL group have been entered. Analyses will be performed for safety (6 months), shunt dependency (12, 24 months), and neurological outcome (60 months).

CONCLUSION

The design and online platform of the TROPHY registry will enable the collection of prospective data on different surgical procedures for investigation of safety, efficacy, and neurodevelopmental outcome of neonates with IVH and hydrocephalus. The long-term goal is to provide valid data on NEL that is prospective, international, and multicenter. With the comparison of different surgical treatment modalities, we hope to develop better therapy guidelines for this complex neurosurgical condition.

Neuroendoscopic lavage for the treatment of CSF infection with hydrocephalus in children

OBJECTIVE

The treatment of infectious CSF condition with ventriculitis and hydrocephalus in children is an interdisciplinary challenge. Conventional surgical treatment includes external ventricular drain (EVD) and systemic antibiotic therapy. However, infectious contamination of large ventricles combined with CSF protein overload often requires long treatment regimens. We retrospectively investigated neuroendoscopic lavage as a new option for clearance of CSF in children with hydrocephalus and active CSF infection.

PATIENTS AND METHODS

A database review identified 50 consecutive patients treated for CSF infection with hydrocephalus at our institution. Twenty-seven patients (control group, CG) were treated conventionally between 2004 and 2010, while 23 patients (neuroendoscopic group, NEG) underwent neuroendoscopic lavage for removal of intraventricular debris between 2010 and 2015. Clinical data, microbiology, laboratory measures, shunt dependency, and shunt revision rate were evaluated retrospectively.

RESULTS

The patient groups did not differ regarding basic clinical characteristics. Patients in NEG received neuroendoscopic lavage at mean of 1.6 ± 1times (1-4). No immediate postoperative complications were observed in NEG patients. Shunt rate in NEG patients was 91% as compared 100% in CG patients (p = 0.109). Within 24 months after shunt implantation, incidence of shunt revision was higher in CG (23/27) compared to NEG (5/23; p < 0.001). Reinfection was observed more often in CG (n = 17) compared to one patient in NEG (p < 0.001).

CONCLUSIONS

We experienced that neuroendoscopic lavage is a safe and effective treatment for hydrocephalus in children with infectious conditions. Neuroendoscopic lavage resulted in a decreased number of overall shunt revisions in shunt-depended patients as well as a lower number of recurrent infections.