Treatment of posthemorrhagic hydrocephalus in premature infants with subcutaneous reservoir drainage

Potential Risk Factors for Ventriculoperitoneal Shunt Implantation in Paediatric Patients with Posthemorrhagic Hydrocephalus of Prematurity Treated with Subcutaneous Reservoir: An Institutional Experience

BACKGROUND

Posthemorrhagic hydrocephalus of prematurity (PHHP) is a result of intraventricular hemorrhage (IVH). IVH occurs in 6 to 23% of the preterms in countries with advanced medical health care. Most of these patients will eventually require the use of ventriculoperitoneal shunt (VPS). The purpose of this study is to assess the risk factors of VPS implantation in patients with PHHP who have been treated with ventricular catheter with subcutaneous reservoir (VCSR).

METHODS

The retrospective study was conducted evaluating 35 premature patients who suffered from severe IVH. Their mean gestational age was 28 weeks. The assessment included antenatal factors such as gestational age, birth weight, and intrauterine and perinatal infection. Postparturient period factors such as the IVH grade, time between diagnosis, and VCSR implantation and body weight on VCSR implantation were also considered in the study. Postprocedural complications, such as bacterial cerebrospinal fluid (CSF) infection, sepsis, and skin lesions, were evaluated. Data were calculated with R program, version 4.04.

RESULTS

From among 35 evaluated patients, 23 (65.71%) required a VPS. Median of birth weight was 1,190 g. Infections were observed in 11 (31.43%) cases. Mean time between IVH diagnosis and VCSR implantation was 2.6 weeks. Postprocedural complications occurred in 19 (54.29%) patients. None of the evaluated factors has proven its statistical significance (p > 0.05) for being a potential risk factor for VPS implantation.

CONCLUSION

External factors seem to not affect the necessity of VPS implantation in patients after the severe IVH. Ostensibly, there seems to be no difference between the grades III and the IV of Papile's IVH scale regarding VPS implantation necessity.

The Cost of Serial Cerebrospinal Fluid Aspirations between Ventricular Access Device and Ventriculosubgaleal Shunt for Treatment of Posthemorrhagic Ventricular Dilatation in Premature Infants

INTRODUCTION

Ventriculosubgaleal shunts (VSGSs) require fewer cerebrospinal (CSF) aspirations than ventricular access devices (VADs) for temporization of posthemorrhagic ventricular dilatation (PHVD) in preterm infants. Cost of postoperative CSF aspiration has not been quantified.

METHODS

We reviewed CSF aspiration and laboratory studies obtained in preterm infants with PHVD and VAD at our institution between 2009 and 2020. Cost per aspiration was calculated for materials, labs, and Medicare fee schedule for ventricular puncture through implanted reservoir. We searched PubMed, Cochrane Library, Embase, CINAHL, and Web of Science for meta-analysis of pooled mean number of CSF aspirations and proportion of patients requiring aspiration.

RESULTS

Thirty-five preterm infants with PHVD had VAD placed with 22.2 ± 18.4 aspirations per patient. Labs were obtained after every aspiration per local protocol. Cost per aspiration at our institution was USD 935.51. Of 269 published studies, 77 reported on VAD, 29 VSGS, and 13 both. Five studies on VAD (including the current study) had a pooled mean of 25.8 aspirations per patient (95% CI: 16.7-34.8). One study on VSGS reported a mean of 1.6 ± 1.7 aspirations. Three studies on VAD (including the current study) had a pooled proportion of 97.4% of patients requiring aspirations (95% CI: 87.9-99.5). Four studies on VSGS had a pooled proportion of 36.5% requiring aspirations (95% CI: 26.9-47.2). Frequency of lab draws ranged from weekly to daily. Based on costs at our institution, mean number of aspirations, and proportion of patients requiring aspirations, cost difference ranged between USD 4,243 and 23,235 per patient and USD 500,903 and 2.36 million per 100 patients depending on frequency of taps and Medicare locality.

DISCUSSION/CONCLUSION

Lower number of CSF aspirations using VSGS can be associated with considerably lower cost compared to VAD.

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.

Treatment of posthemorrhagic ventricular dilation in preterm infants: a systematic review and meta-analysis of outcomes and complications

OBJECT The optimal clinical management of intraventricular hemorrhage (IVH) and posthemorrhagic ventricular dilation (PHVD)/posthemorrhagic hydrocephalus (PHH) in premature infants remains unclear. A common approach involves temporary treatment of hydrocephalus in these patients with a ventriculosubgaleal shunt (VSGS), ventricular access device (VAD), or external ventricular drain (EVD) until it becomes evident that the patient needs and can tolerate permanent CSF diversion (i.e., ventriculoperitoneal shunt). The present systematic review and meta-analysis aimed to provide a robust and comprehensive summary of the published literature regarding the clinical outcomes and complications of these 3 techniques as temporizing measures in the management of prematurity-related PHVD/PHH. METHODS The authors searched MEDLINE, EMBASE, CINAHL, Google Scholar, and the Cochrane Library for studies published through December 2013 on the use of VSGSs, VADs, and/or EVDs as temporizing devices for the treatment of hydrocephalus following IVH in the premature neonate. Data pertaining to patient demographic data, study methods, interventions, and outcomes were extracted from eligible articles. For each of the 3 types of temporizing device, the authors performed meta-analyses examining 6 outcomes of interest, which were rates of 1) obstruction; 2) infection; 3) arrest of hydrocephalus (i.e., permanent shunt independence); 4) mortality; 5) good neurodevelopmental outcome; and 6) revision. RESULTS Thirty-nine studies, representing 1502 patients, met eligibility criteria. All of the included articles were observational studies; 36 were retrospective and 3 were prospective designs. Nine studies (n = 295) examined VSGSs, 24 (n = 962) VADs, and 9 (n = 245) EVDs. Pooled rates of outcome for VSGS, VAD, and EVD, respectively, were 9.6%, 7.3%, and 6.8% for obstruction; 9.2%, 9.5%, and 6.7% for infection; 12.2%, 10.8%, and 47.3% for revision; 13.9%, 17.5%, and 31.8% for arrest of hydrocephalus; 12.1%, 15.3%, and 19.1% for death; and 58.7%, 50.1%, and 56.1% for good neurodevelopmental outcome. CONCLUSIONS This study provides robust estimates of outcomes for the most common temporizing treatments for IVH in premature infants. With few exceptions, the range of outcomes was similar for VSGS, VAD, and EVD.

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.

Ultrasound-guided neuronavigation improves safety of ventricular catheter insertion in preterm infants

BACKGROUND

Intra-ventricular hemorrhage (IVH) is a frequent cause of shunt-dependent hydrocephalus. The management of IVH in preterm babies remains a challenge both for neonatologists and pediatric neurosurgeons, compounded by the lack of low-risk, validated therapy techniques.

OBJECTIVE

The aim of this study was to evaluate the feasibility and safety of a novel technique involving the ultrasound-guided placement of a central catheter connected with a Rickham-Capsule in a cohort of preterm, low-birth-weight babies with post-hemorrhagic hydrocephalus (PHH).

METHODS

Eight preterm infants with PHH in which a Rickham-Capsule was placed from 2008-2012 were included. Conventional surgical techniques were used in four preterm infants; whereas in the other four preterm babies ultrasound guided catheter placement was performed with an 8 MegaHertz (MHz) micro convex transducer from LOGIQ 9, GE Healthcare; whereby the anterior fontanel was used as an acoustic window.

RESULTS

Overall gestational age was 24-31 weeks, mean age at operation was 20.1 (7-36) days, mean birth weight 972.5±370 g, mean weight at first surgical intervention 1023.75±400.4 g. Six patients had bilateral IVH II-III°, two patients had parenchymal involvement. Using the conventional approach, incorrect catheter placement occurred in one of four patients below 1000 g, whereas none of the ultrasound guided cases needed correction.

CONCLUSIONS

Ultrasound-guided neuronavigation represents a relevant tool in the treatment of hydrocephalus in preterm infants through increased accuracy in placement of a central catheter connected to a Rickham-Capsule. The benefit of utilizing this form of neuronavigation needs to be assessed through corresponding standardized studies.

Implantation of Ommaya reservoir in extremely low weight premature infants with posthemorrhagic hydrocephalus: a cautious option

OBJECTIVE

This study aims to evaluate effects and complications of the implantation of Ommaya reservoir in premature infants with posthemorrhagic hydrocephalus (PHH).

METHODS

The effects and complications of the implantation of Ommaya reservoir in seven premature infants with PHH were retrospectively analyzed. Intracapsular puncture of the reservoir was performed for draining cerebrospinal fluid.

RESULTS

Seven extremely low-weight premature infants with PHH (birthweight less than 1,000 g) were treated with the placement of an Ommaya reservoir. Ommaya reservoirs in five infants were removed, but were retained in two infants. Two premature infants had to undergo ventriculoperitoneal (VP) shunt. Postsurgical major complications (including skin dehiscence, cerebrospinal fluid (CSF) infection, ventricular hemorrhage, and CSF leak) occurred in 57% of all patients. Three infants of skin dehiscence and CSF leak occurred. Two infants of CSF infection occurred, as well as one clinically significant secondary hemorrhage. Six infants survived, and one died.

CONCLUSION

The implantation of Ommaya reservoir is a cautious option of treating low-weight premature infants with PHH because of a relatively high complication rate. However, VP shunt surgery may be avoided in some infants.

Effects of the implantation of Ommaya reservoir in children with tuberculous meningitis hydrocephalus: a preliminary study

OBJECTIVE

The role of Ommaya reservoir implantation in children with tuberculous meningitis hydrocephalus (TBMH) has been seldomly reported. Therefore, we performed this study to determine the role of the Ommaya reservoir in the treatment of children with TBMH.

METHODS

We retrospectively analyzed the effects of Ommaya reservoir implantation in 12 children with TBMH. Intracapsular puncture of the reservoir was performed for draining the cerebrospinal fluid and the TBM was treated by intraventricular injection of isoniazid.

RESULTS

The ideal treatment outcome was observed in nine (75 %) of the 12 children; two (16.7 %) children developed serious disabilities and one of them (8.3 %) eventually died. The treatment method was effective for all six (100 %) children with Palur grade II TBM but showed no effect in three (50 %) children with grade III and IV TBM. The number of leukocytes in the cerebrospinal fluid decreased to 20 × 10(6)/L (75 %) within 2 weeks after implantation of the reservoirs. Finally, the Ommaya reservoirs in eight children were removed but were retained in four children. Four children had to undergo ventriculoperitoneal shunt.

CONCLUSION

Ommaya reservoir implantation has been shown to be effective in treating children with TBMH. This method may be largely suitable for children with early grade II TBM or partly in children with grade III TBM who have mild or moderate hydrocephalus that can alleviate after short-term treatment. Thus, a good proportion of children who undergo Ommaya reservoir implantation can avoid ventriculoperitoneal shunt surgery.

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.

Intraparenchymal pericatheter cyst as a complication of a ventriculo-peritoneal shunt in a premature infant

A ventriculo-peritoneal shunt is a standard surgical management for hydrocephalus, but complications may impede the management of this disease. Obstruction of the catheter is one of the most common complications and manifests clinically in various ways. Intraparenchymal cyst development after shunt malfunction has been reported by several authors, but the underlying mechanism and optimal treatment methods are debatable. The authors report a case of intraparenchymal cyst formation around a proximal catheter in a premature infant after a ventriculo-peritoneal shunt and discuss its pathogenesis and management.

Neuronavigation-assisted single transseptal catheter implantation and shunt in patients with posthemorrhagic hydrocephalus and accentuated lateral ventricles dilatation

Background:

To assess the treatment of posthemorrhagic hydrocephalus with accentuated lateral ventricles dilatation by employing a single biventricular neuronavigation-assisted transseptal-implanted catheter with programmable valve and distal peritoneal derivation.

Methods:

A neuronavigation-assisted single transseptal biventricular catheter implantation with distal peritoneal shunt system was performed in 11 patients with posthemorrhagic hydrocephalus and accentuated lateral ventricles dilatations between 2001 and 2010. Patients with concomitant third ventricle dilatation were excluded. Several sequential frustrated attempts of temporary drainage occlusion on both sides confirmed the isolation of the lateral ventricles. Neuronavigation was employed to accurately establish the catheter surgical corridor (trajectory) across the lateral ventricles and throughout the septum pellucidum. The neurological and radiological outcomes were assessed at least 6 months after the procedure.

Results:

Catheter implantation was successfully performed in all patients. Only one catheter was found to be monoventricular on delayed computer tomography controls. Procedure-related complications (bleeding of infections) were not observed. No additional neurological deficits were found after shunt surgery. Six months after procedure, none required additional ventricular catheter implantations or shunt revisions. Radiological and clinical controls confirmed the shunt function and the improved neurological status of all patients.

Conclusion:

Single neuronavigation-assisted transseptal-implanted biventricular catheter is a valid option for the treatment of posthemorrhagic hydrocephalus with accentuated lateral ventricles dilatation. This technique reduces the number of catheters and minimizes the complexity and timing of the surgical procedure as well as potential infection's risks associated with the use of multiple shunting systems.