Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 1: Introduction and methodology

Cerebrospinal fluid shunt malfunctions: A reflective review

PURPOSE

Pediatric hydrocephalus is a common and challenging condition. To date, the ventriculoperitoneal shunt (VPS) is still the main lifesaving treatment option. Nonetheless, it remains imperfect and is associated with multiple short- and long-term complications. This paper is a reflective review of the current state of the VPS, our knowledge gaps, and the future state of shunts in neurosurgical practice.

METHODS AND RESULTS

The authors' reflections are based on a review of shunts and shunt-related literature.

CONCLUSION

Overall, there is still an urgent need for the neurosurgical community to actively improve current strategies for shunt failures and shunt-related morbidity. The authors emphasize the role of collaborative efforts amongst like-minded clinicians to establish pragmatic approaches to avoid shunt complications.

When Pediatric Headaches Are Not Benign-Eye Findings

Headache is the most common neurologic complaint that presents to the pediatrician. While most headaches are benign in nature, patients must be carefully evaluated to rule out life- or vision-threatening causes. Non-benign etiologies of headache may exhibit ophthalmologic signs and symptoms that can help narrow the differential diagnosis. It is also important for physicians to know in what situations appropriate ophthalmologic evaluation is necessary, such as evaluating for papilledema in the setting of elevated intracranial pressure. In this article we discuss life- and/or vision-threatening etiologies of headache, including infection, autoimmune disease, cerebrovascular pathologies, hydrocephalus, intracranial neoplasia, and idiopathic intracranial hypertension, and their associated ophthalmologic manifestations. Due to less familiarity of the disease amongst primary care providers, we discuss pediatric idiopathic intracranial hypertension in more comprehensive detail.

Aetiology and diagnostics of paediatric hydrocephalus across Africa: a systematic review and meta-analysis

BACKGROUND

We aimed to identify the aetiological distribution and the diagnostic methods for paediatric hydrocephalus across Africa, for which there is currently scarce evidence.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE (Ovid), the Cochrane Database of Systematic Reviews (Wiley), Embase (Ovid), Global Health (Ovid), Maternity & Infant Care (Ovid), Scopus, African Index Medicus (Global Index Medicus, WHO) and Africa-Wide Information (EBSCO) from inception to Nov 29, 2021. We included studies from any African country reporting on the distribution of hydrocephalus aetiology in children aged 18 years and younger, with no language restrictions. Hydrocephalus was defined as radiological evidence of ventriculomegaly or associated clinical symptoms and signs of the disorder, or surgical treatment for hydrocephalus. Exclusion criteria were studies only reporting on one specific subgroup or one specific cause of hydrocephalus. We also excluded conference and meetings abstracts, grey literature, editorials, commentaries, historical reviews, systematic reviews, case reports and clinical guidelines, as well as studies on non-humans, fetuses, or post-mortem reports. The proportions of postinfectious hydrocephalus, non-postinfectious hydrocephalus, and hydrocephalus related to spinal dysraphism were calculated using a random-effects model. Additionally, we included a category for unclear cases. Diagnostic methods were described qualitatively. To assess methodological study quality, we applied critical appraisal checklists provided by the Joanna Briggs Institute. The study was registered in Prospero (CRD42020219038).

FINDINGS

Our search yielded 3783 results, of which 1880 (49·7%) were duplicates and were removed. The remaining 1903 abstracts were screened and 122 (6·4%) full articles were sought for retrieval; of these, we included 38 studies from 18 African countries that studied a total of 6565 children. The pooled proportion of postinfectious hydrocephalus was 28% (95% CI 22-36), non-postinfectious hydrocephalus was 21% (95% CI 13-30), and of spinal dysraphism was 16% (95% CI 12-20), with substantial heterogeneity. The pooled proportion of hydrocephalus of unclear aetiology was 20% (95% CI 13-28).

INTERPRETATION

Our findings suggest that postinfectious hydrocephalus is the single most common cause of paediatric hydrocephalus in Africa. For targeted investments to be optimal, there is a need for consensus regarding the aetiological classification of hydrocephalus and improved access to diagnostic services.

FUNDING

Rikshospitalet, Oslo University Hospital, Oslo, Norway.

Prediction of shunt failure facilitated by rapid and accurate volumetric analysis: a single institution's preliminary experience

BACKGROUND

Shunt malfunction is a common complication and often presents with hydrocephalus. While the diagnosis is often supported by radiographic studies, subtle changes in CSF volume may not be detectable on routine evaluation. The purpose of this study was to develop a novel automated volumetric software for evaluation of shunt failure in pediatric patients, especially in patients who may not manifest a significant change in their ventricular size.

METHODS

A single-institution retrospective review of shunted patients was conducted. Ventricular volume measurements were performed using manual and automated methods by three independent analysts. Manual measurements were produced using OsiriX software, whereas automated measurements were produced using the proprietary software. A p value < 0.05 was considered statistically significant.

RESULTS

Twenty-two patients met the inclusion criteria (13 males, 9 females). Mean age of the cohort was 4.9 years (range 0.1-18 years). Average measured CSF volume was similar between the manual and automated methods (169.8 mL vs 172.5 mL, p = 0.56). However, the average time to generate results was significantly shorter with the automated algorithm compared to the manual method (2244 s vs 38.3 s, p < 0.01). In 3/5 symptomatic patients whose neuroimaging was interpreted as stable, the novel algorithm detected the otherwise radiographically undetectable CSF volume changes.

CONCLUSION

The automated software accurately measures the ventricular volumes in pediatric patients with hydrocephalus. The application of this technology is valuable in patients who present clinically without obvious radiographic changes. Future studies with larger cohorts are needed to validate our preliminary findings and further assess the utility of this technology.

The utility of congenital cardiac status to predict endoscopic third ventriculostomy and ventriculoperitoneal shunt failure in hydrocephalic infants

OBJECTIVE

The effect of congenital cardiac status on endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) failure in hydrocephalic infants is unknown. Because cardiac status in infants can impact central venous pressure (CVP), it is possible that congenital heart disease (CHD) and congenital cardiac anomalies may render these cerebrospinal fluid diversion interventions more susceptible to failure. Correspondingly, the aim of this study was to determine how CHD and congenital cardiac anomalies may impact the failure of these initial interventions.

METHODS

A retrospective review of the Nationwide Inpatient Sample (NIS) database was conducted. Infants (aged < 1 year) with known congenital cardiac status managed with either ETV or VPS were included. Quantitative data were compared using either parametric or nonparametric methods, and failure rates were modeled using univariable and multivariable regression analyses.

RESULTS

A total of 18,763 infants treated with ETV or VPS for hydrocephalus were identified in our search, with ETV used to treat 7657 (41%) patients and VPS used to treat 11,106 (59%). There were 6722 (36%) patients who presented with CHD at admission, and a total of 25 unique congenital cardiac anomalies were detected across the cohort. Overall, the most common anomaly was patent ductus arteriosus (PDA) in 4990 (27%) patients, followed by atrial septal defect (ASD) in 2437 (13%) patients and pulmonary hypertension in 810 (4%) patients. With respect to initial intervention failure, 3869 (21%) patients required repeat surgical intervention during admission. This was significantly more common in the ETV group than the VPS group (36% vs 10%, p < 0.01). In both the ETV and VPS groups, CHD (p < 0.01), including all congenital cardiac anomalies, was an independent and significant predictor of failure. ASD (p < 0.01) and PDA (p < 0.01) both significantly predicted ETV failure, and PDA (p < 0.01) and pulmonary hypertension (p = 0.02) both significantly predicted VPS failure.

CONCLUSIONS

These results indicate that congenital cardiac status predicts ETV and VPS failure in patients with infantile hydrocephalus. The authors hypothesized that this finding was primarily due to changes in CVP; however, this may not be completely universal across both interventions and all congenital cardiac anomalies. Future studies about optimization of congenital cardiac status with ETV and VPS are required to understand the practical significance of these findings.

Programmable Shunt Valves for Pediatric Hydrocephalus: 22-Year Experience from a Singapore Children's Hospital

(1) Background: pediatric hydrocephalus is a challenging condition. Programmable shunt valves (PSV) have been increasingly used. This study is undertaken to firstly, to objectively evaluate the efficacy of PSV as a treatment modality for pediatric hydrocephalus; and next, review its associated patient outcomes at our institution. Secondary objectives include the assessment of our indications for PSV, and corroboration of our results with published literature. (2) Methods: this is an ethics-approved, retrospective study. Variables of interest include age, gender, hydrocephalus etiology, shunt failure rates and incidence of adjustments made per PSV. Data including shunt failure, implant survival, and utility comparisons between PSV types are subjected to statistical analyses. (3) Results: in this case, 51 patients with PSV are identified for this study, with 32 index and 19 revision shunts. There are 3 cases of shunt failure (6%). The mean number of adjustments per PSV is 1.82 times and the mean number of adjustments made per PSV is significantly lower for MEDTRONIC™ Strata PSVs compared with others (p = 0.031). Next, PSV patients that are adjusted more frequently include cases of shunt revisions, PSVs inserted due to CSF over-drainage and tumor-related hydrocephalus. (4) Conclusion: we describe our institutional experience of PSV use in pediatric hydrocephalus and its advantages in a subset of patients whose opening pressures are uncertain and evolving.

Craniosynostosis Develops in Half of Infants Treated for Hydrocephalus with a Ventriculoperitoneal Shunt

BACKGROUND

Craniosynostosis following placement of a ventriculoperitoneal shunt for hydrocephalus has been sporadically described. The purpose of this investigation was to determine the general risk of developing craniosynostosis in this patient population.

METHODS

The authors retrospectively reviewed records and radiographs of infants who underwent ventriculoperitoneal shunt placement for hydrocephalus from 2006 to 2012. Recorded variables included date of shunt placement, demographics, comorbidities, cause of hydrocephalus, shunt type, and number of shunt revisions. Axial computed tomographic images obtained before and immediately after shunt placement and 2 to 4 years after shunt placement were evaluated by a panel of clinicians for evidence of craniosynostosis. Patients with preshunt craniosynostosis, craniosynostosis syndromes, or poor-quality computed tomographic images were excluded. Data were analyzed using STATA Version 15.1 statistical software.

RESULTS

One hundred twenty-five patients (69 male and 56 female patients) were included. Average age at shunt placement was 2.3 ± 2.58 months. Sixty-one patients (48.8 percent) developed craniosynostosis at a median of 26 months after shunt placement. Of these, 28 patients fused one suture; the majority involved the sagittal suture (n = 25). Thirty-three patients fused multiple sutures; the most common were the coronal (n = 32) and the sagittal (n = 30) sutures. Multivariable logistic regression identified older age at shunt placement and more shunt revisions as independent predictors of craniosynostosis. Shunt valve type was not significant.

CONCLUSIONS

Craniosynostosis developed in nearly half of infants who underwent ventriculoperitoneal shunt placement for hydrocephalus. The sagittal suture was most commonly involved. The effect of suture fusion on subsequent cranial growth, shunt failure, or the development of intracranial pressure is unclear.

CLINICAL QUESITON/LEVEL OF EVIDENCE

Risk, III.

A new surgical method of treatment spontaneous intracranial hemorrhage

Objective

This study aimed to determine the safety and effectiveness of DTI-assisted neuroendoscopy for treating intracranial hemorrhage (ICH).

Methods

This retrospective study included clinical data from 260 patients with spontaneous supratentorial ICH who received neuroendoscopic hematoma removal. Patients were separated into groups based on the surgery method they received: DTI-assisted neuroendoscopy (69 cases) and standard neuroendoscopy (191 cases). All patients were followed up for 6 months. Multivariate logistic regression analyzed the risk factors affecting the prognosis of patients. The outcomes of the two groups were compared using Kaplan-Meier survival curves.

Results

The prognostic modified Rankin Scale (mRS) score was significantly better (P = 0.027) in the DTI-assisted neuroendoscopy group than in the standard neuroendoscopy group. Logistic regression analysis showed that DTI-assisted neuroendoscopy is an independent protective factor for a favorable outcome (model 1: odds ratio [OR] = 0.42, P = 0.015; model 2: OR = 0.40, P = 0.013). Kaplan-Meier survival curves were used to show that the median time for a favorable outcome was 66 days (95% confidence interval [CI] = 48.50-83.50 days) in the DTI-assisted neuroendoscopy group and 104 days (95% CI = 75.55-132.45 days) in the standard neuroendoscopy group. Log-rank testing showed that the DTI-assisted neuroendoscopy group had a lower pulmonary infection rate (χ ² = 4.706, P = 0.030) and a better prognosis (χ ² = 5.223, P = 0.022) than the standard neuroendoscopy group. The survival rate did not differ significantly between the DTI-assisted neuroendoscopy group and the standard neuroendoscopy group (P > 0.05).

Conclusions

The use of DTI in neuroendoscopic hematoma removal can significantly improve neurological function outcomes in patients, but it does not significantly affect the mortality of patients.

The Role of Prophylactic Intraventricular Antibiotics in Reducing the Incidence of Infection and Revision Surgery in Pediatric Patients Undergoing Shunt Placement

BACKGROUND

Ventriculoperitoneal shunt placement remains the primary treatment modality for children with hydrocephalus. However, morbidity and revision surgery secondary to infection remains high, even while using antibiotic-impregnated shunts.

OBJECTIVE

To determine whether intraoperative injection of antibiotics is independently associated with reduced rates of infection and revision surgery in children undergoing shunt placement.

METHODS

This is an analysis of a prospectively collected, multicenter, shunt-specific neurosurgical registry consisting of data from over 100 hospitals collected between 2016 and 2017. All patients under 18 yr of age undergoing first-time shunt placement for the definitive treatment of hydrocephalus were included. The primary exposure of interest was injection of intraventricular antibiotics into the shunt catheter following shunt placement and prior to closure. The use of additional surgical adjuncts, such as antibiotic-impregnated shunts, stereotactic guidance, and endoscopy was collected. The primary outcome metric was the need for additional intervention because of an infection.

RESULTS

A total of 2007 pediatric patients undergoing shunt placement for hydrocephalus were identified. Postoperatively, 97 (4.8%) patients had additional intervention secondary to infection. In a multivariable regression model controlling for patient characteristics, etiology of hydrocephalus, prior temporizing measures, and placement of an antibiotic-impregnated shunt, injection of intraventricular antibiotics was associated with a significant reduction in postoperative infections (odds ratio = 0.29, 95% CI: 0.04-0.89, P = .038). Of those receiving intraventricular antibiotics, only 2 (0.38%) went on to undergo re-intervention due to infection.

CONCLUSION

These data suggest that for this select group of patients, use of intraventricular antibiotics was associated with decreased rates of re-intervention secondary to infection.

Infant hydrocephalus: what valve first?

PURPOSE

To review the use of different valve types in infants with hydrocephalus, in doing so, determining whether an optimal valve choice exists for this patient cohort.

METHODS

We conducted (1) a literature review for all studies describing valve types used (programmable vs. non-programmable, valve size, pressure) in infants (≤ 2 years) with hydrocephalus, (2) a review of data from the pivotal BASICS trial for infant patients and (3) a separate, institutional cohort study from Alder Hey Children's Hospital NHS Foundation Trust. The primary outcome was any revision not due to infection.

RESULTS

The search identified 19 studies that were included in the review. Most did not identify a superior valve choice between programmable and non-programmable, small compared to ultra-small, and differential pressure compared to flow-regulating valves. Five studies investigated a single-valve type without a comparator group. The BASICS data identified 391 infants, with no statistically significant difference between gravitational and programmable subgroups. The institutional data from our tertiary referral centre did not reveal any significant difference in failure rate between valve subtypes.

CONCLUSION

Our review highlights the challenges of valve selection in infant hydrocephalus, reiterating that the concept of an optimal valve choice in this group remains a controversial one. While the infant-hydrocephalic population is at high risk of valve failure, heterogeneity and a lack of direct comparison between valves in the literature limit our ability to draw meaningful conclusions. Data that does exist suggests at present that there is no difference in non-infective failure rate are increasing in number, with the British valve subtypes in infant hydrocephalus, supported by both the randomised trial and institutional data in this study.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Treatment of Pediatric Hydrocephalus: Update of the 2014 Guidelines

BACKGROUND

The Congress of Neurological Surgeons reviews its guidelines according to the Institute of Medicine's recommended best practice of reviewing guidelines every 5 yrs. The authors performed a planned 5-yr review of the medical literature used to develop the “Pediatric hydrocephalus: systematic literature review and evidence-based guidelines” and determined the need for an update to the original guideline based on new available evidence.

OBJECTIVE

To perform an update to include the current medical literature for the “Pediatric hydrocephalus: systematic literature review and evidence-based guidelines”, originally published in 2014.

METHODS

The Guidelines Task Force used the search terms and strategies consistent with the original guidelines to search PubMed and Cochrane Central for relevant literature published between March 2012 and November 2019. The same inclusion/exclusion criteria were also used to screen abstracts and to perform the full-text review. Full text articles were then reviewed and when appropriate, included as evidence and recommendations were added or changed accordingly.

RESULTS

A total of 41 studies yielded by the updated search met inclusion criteria and were included in this update.

CONCLUSION

New literature resulting from the update yielded a new recommendation in Part 2, which states that neuro-endoscopic lavage is a feasible and safe option for the removal of intraventricular clots and may lower the rate of shunt placement (Level III). Additionally a recommendation in part 7 of the guideline now states that antibiotic-impregnated shunt tubing reduces the risk of shunt infection compared with conventional silicone hardware and should be used for children who require placement of a shunt (Level I). &lt;https://www.cns.org/guidelines/browse-guidelines-detail/pediatric-hydrocephalus-guideline&gt;

Coccidioidal Meningitis in New York Traced to Texas by Fungal Genomic Analysis

A child developed hydrocephalus. Sixteen months later, it was discovered to be a complication of coccidioidal meningitis. The infection's source was uncertain until genomic analysis of the fungal isolate identified its origin to be a visit to Beeville, Texas. Improved national reporting of cases of coccidioidomycosis might reduce diagnostic delays.

When Opposites Attract: Pediatric Cochlear Implantation in the Setting of Cerebrospinal Fluid Shunts

OBJECTIVE

The Food and Drug Administration (FDA) has recently raised concern regarding the safety of cochlear implantation in the setting of programmable cerebrospinal fluid shunts. The purpose of this study was to evaluate the outcomes and complications of cochlear implantation in children who have a cerebrospinal fluid shunt.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary academic referral center.

PATIENTS

Twenty pediatric subjects with a cerebrospinal fluid shunt and cochlear implant (CI).

INTERVENTION

Cochlear implantation in the setting of a cerebrospinal fluid shunt.

MAIN OUTCOME MEASURES

Primary outcome measures included descriptive data regarding age at implantation, etiology of hearing loss, medical management, complications, and speech perception outcomes.

RESULTS

The average age of CI candidacy was 30 months with an average 21.5 months delay to implantation. In 45% of cases the laterality of the shunt determined the ear to be implanted. Three of the subjects required a surgical intervention on the shunt before cochlear implantation. Three subjects had a concurrently programmable shunt and activated CI. Two of the three subjects had no complications as a result of the two devices; however, the third subject had significant interactions requiring multiple revision surgeries. For those with the cognitive ability to perform open set, recoded speech perception, the average postoperative Consonant Nucleus Consonant word score in the best aided condition was 65.2% (n = 5).

CONCLUSIONS

Children with a cerebrospinal fluid shunt are viable candidates for cochlear implantation, although they often require additional procedures and considerations before and after implantation.

Improving health care transition and longitudinal care for adolescents and young adults with hydrocephalus: report from the Hydrocephalus Association Transition Summit

The health care needs of children with hydrocephalus continue beyond childhood and adolescence; however, pediatric hospitals and pediatric neurosurgeons are often unable to provide them care after they become adults. Each year in the US, an estimated 5000-6000 adolescents and young adults (collectively, youth) with hydrocephalus must move to the adult health care system, a process known as health care transition (HCT), for which many are not prepared. Many discover that they cannot find neurosurgeons to care for them. A significant gap in health care services exists for young adults with hydrocephalus. To address these issues, the Hydrocephalus Association convened a Transition Summit in Seattle, Washington, February 17-18, 2017.The Hydrocephalus Association surveyed youth and families in focus groups to identify common concerns with HCT that were used to identify topics for the summit. Seven plenary sessions consisted of formal presentations. Four breakout groups identified key priorities and recommended actions regarding HCT models and practices, to prepare and engage patients, educate health care professionals, and address payment issues. The breakout group results were discussed by all participants to generate consensus recommendations.Barriers to effective HCT included difficulty finding adult neurosurgeons to accept young adults with hydrocephalus into their practices; unfamiliarity of neurologists, primary care providers, and other health care professionals with the principles of care for patients with hydrocephalus; insufficient infrastructure and processes to provide effective HCT for youth, and longitudinal care for adults with hydrocephalus; and inadequate compensation for health care services.Best practices were identified, including the National Center for Health Care Transition Improvement's "Six Core Elements of Health Care Transition 2.0"; development of hydrocephalus-specific transition programs or incorporation of hydrocephalus into existing general HCT programs; and development of specialty centers for longitudinal care of adults with hydrocephalus.The lack of formal HCT and longitudinal care for young adults with hydrocephalus is a significant health care services problem in the US and Canada that professional societies in neurosurgery and neurology must address. Consensus recommendations of the Hydrocephalus Association Transition Summit address 1) actions by hospitals, health systems, and practices to meet local community needs to improve processes and infrastructure for HCT services and longitudinal care; and 2) actions by professional societies in adult and pediatric neurosurgery and neurology to meet national needs to improve processes and infrastructure for HCT services; to improve training in medical and surgical management of hydrocephalus and in HCT and longitudinal care; and to demonstrate the outcomes and effectiveness of HCT and longitudinal care by promoting research funding.

Complications and 3-month outcomes of children with hydrocephalus treated with ventriculoperitoneal shunts in Malawi

OBJECTIVE

Hydrocephalus is the most common pediatric neurosurgical condition, with a high prevalence in low- and middle-income countries. Untreated, hydrocephalus leads to neurological disability or death. The epidemiology and outcomes of hydrocephalus treated by ventriculoperitoneal (VP) shunts in Sub-Saharan Africa are not well defined and vary by region. The aim of the present study was to examine the mortality and morbidity rates and predictors of mortality in children treated by VP shunt placement for hydrocephalus at Kamuzu Central Hospital in Lilongwe, Malawi.

METHODS

This is a prospective study of 100 consecutive children presenting with hydrocephalus who were treated with VP shunt placement from January 2015 to August 2017. Demographics, nutritional status, maternal characteristics, developmental delay, shunt complications, readmissions, and in-hospital and 3-month mortality data were collected. Multivariate logistic regression was used to identify predictors of death within 3 months of surgery.

RESULTS

Overall, 46% of participants were female, with an average age of 5.4 ± 3.7 months at the time of surgery. The majority of patients were term deliveries (87.8%) and were not malnourished (72.9%). Only 10.8% of children were diagnosed with meningitis before admission. In-hospital and 3-month mortality rates were 5.5% and 32.1%, respectively. The only significant association with mortality was maternal age, with older maternal age demonstrating decreased odds of 3-month mortality (OR 0.9, 95% CI 0.8-1.0, p = 0.045).

CONCLUSIONS

Surgical management of hydrocephalus with VP shunts portends a high mortality rate in Malawi. The association of younger maternal age with mortality is likely a proxy for social determinants, which appear to contribute as much to mortality as patient factors. VP shunting is inadequate as a sole surgical management of hydrocephalus in resource-limited settings.

Automated Ventricular System Segmentation in Paediatric Patients Treated for Hydrocephalus Using Deep Learning Methods

Hydrocephalus is a common neurological condition that can have traumatic ramifications and can be lethal without treatment. Nowadays, during therapy radiologists have to spend a vast amount of time assessing the volume of cerebrospinal fluid (CSF) by manual segmentation on Computed Tomography (CT) images. Further, some of the segmentations are prone to radiologist bias and high intraobserver variability. To improve this, researchers are exploring methods to automate the process, which would enable faster and more unbiased results. In this study, we propose the application of U-Net convolutional neural network in order to automatically segment CT brain scans for location of CSF. U-Net is a neural network that has proven to be successful for various interdisciplinary segmentation tasks. We optimised training using state of the art methods, including “1cycle” learning rate policy, transfer learning, generalized dice loss function, mixed float precision, self-attention, and data augmentation. Even though the study was performed using a limited amount of data (80 CT images), our experiment has shown near human-level performance. We managed to achieve a 0.917 mean dice score with 0.0352 standard deviation on cross validation across the training data and a 0.9506 mean dice score on a separate test set. To our knowledge, these results are better than any known method for CSF segmentation in hydrocephalic patients, and thus, it is promising for potential practical applications.

Tales from the Night:: Emergency MR Imaging in Pediatric Patients after Hours

Overnight in-house radiology has rapidly become an important part of contemporary practice models, and is increasingly the norm in pediatric radiology. MR imaging is an indispensable first-line and problem-solving tool in the pediatric population. This has led to increasingly complex MR imaging being performed "after hours" on pediatric patients. This article reviews the factors that have led to widespread overnight subspecialty radiology and the associated challenges for overnight radiologists, and provides an overview of up-to-date imaging techniques and imaging findings of the most common indications for emergent MR imaging in the pediatric population.

Bone Overgrowth Causing Proximal Ventriculoperitoneal Shunt Malfunction

BACKGROUND

Hydrocephalus is an international disease process that is commonly treated surgically with a ventriculoperitoneal shunt. This device may be prone to malfunction, most commonly from obstruction, disconnection, or infection.

CASE DESCRIPTION

A 35-year-old female with hydrocephalus and a ventriculoperitoneal shunt presented with altered mental status and imaging concerning for a shunt malfunction. Intraoperatively, she was found to have bone growing over and compressing the proximal occluder of the shunt valve, causing a mechanical obstruction. Removal of the bone allowed for egress of cerebrospinal fluid and return of proper shunt function. The patient did well postoperatively.

CONCLUSION

Hydrocephalus, ventriculoperitoneal shunts, and shunt revisions represent a significant health burden and cost. Here we present an unusual cause of a shunt malfunction caused by bony overgrowth.

Early surgical management and long-term surgical outcome for intraventricular hemorrhage-related posthemorrhagic hydrocephalus in shunt-treated premature infants

OBJECTIVE Perinatal intraventricular hemorrhage (IVH) in premature neonates may lead to severe neurological disability and lifelong treatment requirement for consecutive posthemorrhagic hydrocephalus (PHHC). Early CSF diversion as a temporizing measure, or a permanent ventriculoperitoneal shunt (VPS), is the treatment of choice. Preterm neonates are not only at high risk for different perinatal but also for treatment-related complications. The authors reviewed their institutional neurosurgical management for preterm neonates with IVH-related PHHC and evaluated shunt-related surgical outcome for this particular hydrocephalus etiology after completion of a defined follow-up period of 5 years after initial shunt insertion. METHODS The authors retrospectively analyzed early surgical management for preterm newborns who presented with IVH and PHHC between 1995 and 2015. According to the guidelines, patients received implantation of a ventricular access device (VAD) for temporizing measures or direct VPS insertion as first-line surgical treatment. Surgical outcome was evaluated for a subgroup of 72 patients regarding time to first shunt revision and the mean number of shunt revisions during a time span of 5 years after initial shunt insertion. Gestational age (GA), extent of IVH, and timing and modality of initial surgical intervention were analyzed for potential impact on corresponding surgical outcome. RESULTS A total cohort of 99 preterm newborns with GAs ranging from 22 to 36 weeks (mean 28.3 weeks) with perinatal IVH-related PHHC and a median follow-up duration of 9.9 years postpartum could be selected for further investigation. Extent of perinatal IVH was defined as grade III or as periventricular hemorrhagic infarction in 75% of the patient cohort. Seventy-six patients (77%) underwent VAD insertion and temporizing measures as initial surgical treatment; for 72 (95%) of these a later conversion to permanent ventriculoperitoneal shunting was performed, and 23 patients received direct VPS insertion. Etiological and treatment-related variables revealed no significant impact on revision-free shunt survival but increased the mean numbers of shunt revisions after 5 years for low GA, higher-order IVH in the long term. CONCLUSIONS Low GA and higher-order IVH in preterm neonates with PHHC who are treated with VPSs show no significant impact on time to first shunt revision (i.e., revision-free shunt survival), but marked differences in mean revision rates evaluated after completion of 5 years of follow-up. Temporizing measures via a VAD represent a rational strategy to gain time and decision guidance in preterm patients with PHHC before permanent VPS insertion.

Implementing a digital real-time Hydrocephalus and Shunt Registry to evaluate contemporary pattern of care and surgical outcome in pediatric hydrocephalus

OBJECTIVE

Treatment monitoring and outcome evaluation in pediatric hydrocephalus require gapless documentation regarding surgical and clinical follow-up data beginning from day 1 of treatment in order to apply high quality of care. Endoscopic procedures, shunt insertion and revision surgeries, and individual modifications of valve hardware or pressure settings during follow-up as well as established outcome measurements are highly relevant for complete illustration of the patient's hydrocephalus histories. A digital tool to capture, organize, and analyze comprehensive treatment-related data was estimated long overdue, consequentially developed, and implemented in daily pediatric neurosurgical routine.

METHODS

We established a self-contained, network-capable database application to supply and back up clinical information of complete surgical treatment history with implant status and follow up for all institutional pediatric hydrocephalus patients from 1995 to date. The application content has been prospectively complemented since 2012 during daily pediatric neurosurgical routine. Beside surgical data, neurological outcome and quality of life assessment were integrated according to validated scales to be recordable 2, 3, and 5 years after initial surgical intervention for prospective administration. The application is in continuous and problem-free use since implementation offering homogeneous and structured real-time information of surgical and corresponding neurological hydrocephalus-related data. By using an automatized data extraction tool, an exemplary surgical outcome evaluation reviewing institutional ventriculo-peritoneal shunt (VPS) treatment in infants over a period of more than 20 years was performed. To validate applicability, the Registry was successfully implemented in an external institution under identical conditions continuously serving for the same purpose until today.

RESULTS

Upon completion of the developing process, the application was successfully implemented into routine clinical workflow of our institution. In total, 579 pediatric hydrocephalus patients entered into the Registry with collectively 1874 corresponding hydrocephalus-related surgeries (9% neuro-endoscopic procedures, 18% temporary CSF-diversions, 73% shunt surgeries) so far. For exemplary surgical outcome analysis, the total volume of complex data sets could easily be reduced stepwise in regard to requested inclusion criteria. The selection process generated conclusive data of 256 institutional pediatric VPS patients providing a median follow-up of 8.5 years. Surgical outcome was evaluated in regard to hydrocephalus etiology, applied valve design, valve augmentation, cause of initial malfunction, time to initial shunt revision, and number of total revisions.

CONCLUSION

The pediatric hydrocephalus registry application delivers easy access to contemporary and up-to-date clinical information during daily clinical routine and proves comprehensive value for various scientific purposes. Institutional hydrocephalus etiologies, treatment modalities, and surgical outcome could be reviewed for a selected pediatric patient collective during an interval of more than 20 years and confirmed initial shunt treatment within the first year of age, communicating hydrocephalus and a history of prematurity as significant variables for unfavorable shunt survival and long-term revision rate. At our institution, the Registry emerged to an essential and sustainable tool to capture, organize, and analyze patterns of care in pediatric hydrocephalus patients of all etiologies and treatment modalities. Because of its adaptable and reliable predicate, a prospective multi-center utilization is currently in preparation.

I can hear my shunt-audible noises associated with CSF shunts in hydrocephalic patients

BACKGROUND

Cerebrospinal fluid (CSF) shunts are life-long implants, and patients have reported anecdotally on noises associated with their shunts. There is, however, a marked lack of information regarding acoustic phenomena related to CSF shunts.

METHODS

We identified all patients who had been treated or followed in our neurosurgical department within a 15-year period from January 2000 up to the end of 2014. After approval of the local ethics committee all patients who were cognitively intact were explored by a questionnaire and by personal interview about acoustic phenomena related to their shunts.

RESULTS

Three hundred forty-seven patients were eligible for the survey, and 260 patients completed the questionnaire. Twenty-nine patients (11.2%) reported on noises raised by their shunts. All of them experienced short-lasting noises while changing body posture, mainly from a horizontal to an upright position, or while reclining the head. Most of the patients reported on soft sounds, but loud and even very loud noises occurred in some patients. Seventy-six percent of the patients were not bothered by these noises as they considered it as a normal part of the therapy or as proof that the shunt device was functioning. Modern valves with gravitational units are prone to produce noises in young adults, but nearly all valve types can evoke noises.

CONCLUSIONS

Noises caused by a shunt do occur in a considerable number of patients with shunts. One should be aware of this phenomenon, and these patients must be taken seriously.

Imaging of Ventriculoperitoneal Shunt Complications: Comparison of Whole Body Low-Dose Computed Tomography and Radiographic Shunt Series

OBJECTIVE

To determine diagnostic value and radiation exposure of low-dose computed tomography (LD-CT) compared to radiographic shunt series (SS) for the detection of ventriculoperitoneal (VP) shunt complications.

METHODS

Fourteen VP shunts were implanted in 7 swine cadavers. Mechanical complications were induced in 50% of VP shunts. Low-dose CT (80 kVp, 10 mAs, Pitch = 1.5) and SS were acquired. Dose area product (DAP) and effective doses for SS and LD-CT were collected. Scoring of diagnostic confidence and blinded readings of SS and CT data were performed.

RESULTS

The sensitivity of LD-CT was high (0.97; 95% confidence interval, 0.91-1.00) with excellent interobserver agreement (κ = 0.88). Similarly, the sensitivity of SS was high (0.82; 95% confidence interval, 0.68-0.95) with good interobserver agreement (κ = 0.68). In contrast, LD-CT was associated with significantly higher diagnostic confidence (4.64 ± 0.41 vs 2.71 ± 0.73; P < 0.01) and significantly lower radiation exposure (effective dose: 0.26 mSv vs 1.06 mSv; DAP: 265.4 μGym vs 724.8 μGym; P < 0.001).

CONCLUSIONS

For the assessment of suspected VP shunt complications, LD-CT provides excellent sensitivity and higher diagnostic confidence with lower radiation exposure compared with SS.

High-Pitch Low-Dose Whole-Body Computed Tomography for the Assessment of Ventriculoperitoneal Shunts in a Pediatric Patient Model: An Experimental Ex Vivo Study in Rabbits

OBJECTIVE

The aim of this study was to assess the diagnostic value of whole-body low-dose (LD) computed tomography (CT) for the detection of ventriculoperitoneal (VP) shunt complications in pediatric patients compared with radiographic shunt series (SS) in an ex vivo rabbit animal model.

METHODS

In the first step, 2 optimized LD-CT imaging protocols, with high pitch (pitch, 3.2), low tube voltages (70 kVp and 80 kVp), and using both filtered back projection and iterative reconstruction, were assessed on a 16-cm solid polymethylmethacrylate phantom regarding signal-to-noise ratio and radiation dose. Taking both radiation dose and signal-to-noise ratio into account, the LD-CT protocol (80 kVp; 4 mA; pitch, 3.2) was identified as most appropriate and therefore applied in this study.After identification of appropriate LD-CT protocol, 12 VP shunts were implanted in 6 rabbit cadavers (mean weight, 5.1 kg). Twenty-four mechanical complications (extracranial and extraperitoneal malpositioning, breakages, and disconnections) were induced in half of the VP shunts. Low-dose CT and conventional SS were acquired in standard fashion. Dose-area products (DAPs) for SS and LD-CT were collected; effective radiation doses for both SS and LD-CT were estimated using CT-Expo (v. 2.3.1.) and age-specific effective dose (ED) estimates. Qualitative scoring of diagnostic confidence on a 5-point Likert scale (1, very low diagnostic confidence; 5, excellent diagnostic confidence) and blinded readings of both SS and LD-CTs were performed.

RESULTS

Among the 24 VP shunt complications, LD-CT yielded excellent sensitivity and specificity for the detection of VP shunt complications (sensitivity, 0.98; specificity, 1; 95% confidence interval, 0.92-1) with excellent interobserver agreement (κ = 0.90). Shunt series yielded good sensitivity and specificity (sensitivity, 0.75; specificity, 1; 95% confidence interval, 0.58-0.92) with moderate interobserver agreement (κ = 0.56). No false-positive findings were registered. Compared with SS, LD-CT yielded significantly lower ED and DAPs (ED, 0.039 vs 0.062 mSv; DAP, 20.5 vs 26.3; P < 0.05).

CONCLUSIONS

In this experimental ex vivo pediatric patient model, LD-CT yields excellent sensitivity for the detection of VP shunt complications at higher diagnostic confidence and lower radiation exposure compared with SS.

Hydrocephalus in children

Hydrocephalus is a common disorder of cerebral spinal fluid (CSF) physiology resulting in abnormal expansion of the cerebral ventricles. Infants commonly present with progressive macrocephaly whereas children older than 2 years generally present with signs and symptoms of intracranial hypertension. The classic understanding of hydrocephalus as the result of obstruction to bulk flow of CSF is evolving to models that incorporate dysfunctional cerebral pulsations, brain compliance, and newly characterised water-transport mechanisms. Hydrocephalus has many causes. Congenital hydrocephalus, most commonly involving aqueduct stenosis, has been linked to genes that regulate brain growth and development. Hydrocephalus can also be acquired, mostly from pathological processes that affect ventricular outflow, subarachnoid space function, or cerebral venous compliance. Treatment options include shunt and endoscopic approaches, which should be individualised to the child. The long-term outcome for children that have received treatment for hydrocephalus varies. Advances in brain imaging, technology, and understanding of the pathophysiology should ultimately lead to improved treatment of the disorder.

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.

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 4: Cerebrospinal fluid shunt or endoscopic third ventriculostomy for the treatment of hydrocephalus in children

OBJECT

The objective of this systematic review was to examine the existing literature comparing CSF shunts and endoscopic third ventriculostomy (ETV) for the treatment of pediatric hydrocephalus and to make evidence-based recommendations regarding the selection of surgical technique for this condition.

METHODS

Both the US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words specifically chosen to identify published articles detailing the use of CSF shunts and ETV for the treatment of pediatric hydrocephalus. Articles meeting specific criteria that had been determined a priori were examined, and data were abstracted and compiled in evidentiary tables. These data were then analyzed by the Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force to consider treatment recommendations based on the evidence.

RESULTS

Of the 122 articles identified using optimized search parameters, 52 were recalled for full-text review. One additional article, originally not retrieved in the search, was also reviewed. Fourteen articles met all study criteria and contained comparative data on CSF shunts and ETV. In total, 6 articles (1 Class II and 5 Class III) were accepted for inclusion in the evidentiary table; 8 articles were excluded for various reasons. The tabulated evidence supported the evaluation of CSF shunts versus ETV.

CONCLUSIONS

Cerebrospinal fluid shunts and ETV demonstrated equivalent outcomes in the clinical etiologies studied.

RECOMMENDATION

Both CSF shunts and ETV are options in the treatment of pediatric hydrocephalus.

STRENGTH OF RECOMMENDATION

Level II, moderate clinical certainty.

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 10: Change in ventricle size as a measurement of effective treatment of hydrocephalus

OBJECT

The objective of this systematic review is to answer the following question: Does ventricle size after treatment have a predictive value in determining the effectiveness of surgical intervention in pediatric hydrocephalus?

METHODS

The US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were searched using MeSH headings and key words relevant to change in ventricle size after surgical intervention for hydrocephalus in children. An evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III).

RESULTS

Six articles satisfied inclusion criteria for the evidentiary tables for this part of the guidelines. All were Class III retrospective studies. CONCLUSIONS/RECOMMENDATIon: There is insufficient evidence to recommend a specific change in ventricle size as a measurement of the effective treatment of hydrocephalus and as a measurement of the timing and effectiveness of treatments including ventriculoperitoneal shunts and third ventriculostomies.

STRENGTH OF RECOMMENDATION

Level III, unclear clinical certainty.

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 8: Management of cerebrospinal fluid shunt infection

OBJECT

The objective of this systematic review was to answer the following question: What is the optimal treatment strategy for CSF shunt infection in pediatric patients with hydrocephalus?

METHODS

The US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I-III). Evidentiary tables were constructed that summarized pertinent study results, and based on the quality of the literature, recommendations were made (Levels I-III).

RESULTS

A review and critical appraisal of 27 studies that met the inclusion criteria allowed for a recommendation for supplementation of antibiotic treatment using partial (externalization) or complete shunt hardware removal, with a moderate degree of clinical certainty. However, a recommendation regarding whether complete shunt removal is favored over partial shunt removal (that is, externalization) could not be made owing to severe methodological deficiencies in the existing literature. There is insufficient evidence to recommend the use of intrathecal antibiotic therapy as an adjunct to systemic antibiotic therapy in the management of routine CSF shunt infections. This also holds true for other clinical scenarios such as when an infected CSF shunt cannot be completely removed, when a shunt must be removed and immediately replaced in the face of ongoing CSF infection, or when the setting is ventricular shunt infection caused by specific organisms (for example, gram-negative bacteria).

CONCLUSIONS

Supplementation of antibiotic treatment with partial (externalization) or complete shunt hardware removal are options in the management of CSF shunt infection. There is insufficient evidence to recommend either shunt externalization or complete shunt removal as the preferred surgical strategy for the management of CSF shunt infection. Therefore, clinical judgment is required. In addition, there is insufficient evidence to recommend the combination of intrathecal and systemic antibiotics for patients with CSF shunt infection when the infected shunt hardware cannot be fully removed, when the shunt must be removed and immediately replaced, or when the CSF shunt infection is caused by specific organisms. The potential neurotoxicity of intrathecal antibiotic therapy may limit its routine use.

RECOMMENDATION

Supplementation of antibiotic treatment with partial (externalization) or with complete shunt hardware removal is an option in the management of CSF shunt infection.

STRENGTH OF RECOMMENDATION

Level II, moderate degree of clinical certainty.

RECOMMENDATION

There is insufficient evidence to recommend either shunt externalization or complete shunt removal as a preferred surgical strategy for the management of CSF shunt infection. Therefore, clinical judgment is required.

STRENGTH OF RECOMMENDATION

Level III, unclear degree of clinical certainty.

RECOMMENDATION

There is insufficient evidence to recommend the combination of intrathecal and systemic antibiotics for patients with CSF shunt infection in whom the infected shunt hardware cannot be fully removed or must be removed and immediately replaced, or when the CSF shunt infection is caused by specific organisms. The potential neurotoxicity of intrathecal antibiotic therapy may limit its routine use.

STRENGTH OF RECOMMENDATION

Level III, unclear degree of clinical certainty.